FREE HAIR LOSS EVALUATION

Please fill out the following form, and submit it to us for your free confidential hair loss evaluation by our staff.
First Name:  
Last Name:  
Address:  
City:  
State:  
Zip:  
Email:  
Primary Phone:  
Evening Phone:  
Year of Birth  
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Please tell us about the kind of hair loss you are experiencing:
1. How long have you been losing your hair?
1-3 Years 3-7 Years 7-15 Years More than 15 years
2. Where has the hair loss occurred?
(A) (B) (C) (D) (E)
3. Is the scalp visible in the area where you have lost your hair?
Yes No
4. Do you suffer from ? (choose as many as applicable)
Dandruff Itchy Scalp Dry Scalp Oily Scalp
5. WOuld you characterize your existing hair as (choose one)
Dry Oily Normal
6. Is the hair growing on the sides of your head? (Choose one)
Thin & Full Thick & Full Thin & Slightly Receding
7. Does your scalp excrete excessive oils?
Yes No
8. Have you ever experienced a build-up of oil on your scalp?
Yes No
9. Does your scalp ever flake?
Yes No
10. Do you ever see red blotches on your scalp?
Yes No
11. How would you rate your current rate of hair loss? (choose one)
Light Moderate Heavy
12. Have you experienced an increase in your rate of hair loss in the past?
Yes No
13. Have you ever tried to do anything about your hair loss?
Rogaine  
Hair Transplant  
Hair Replacement  
Lotions / Shampoos  
Nothing  
14. Have you ever seen a doctor about your hair loss?
Yes No

15. Why do you want to do anything about your hair?

I look older than I feel  
I hate the way my hair looks  
Other  
16. Do you want to:
Stop your hair loss? Have more hair?
17. When would you like to schedule an appointment?



 
 
 
 
Schedule A Hair Loss Evaluation Today What Causes Hair Loss?
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Des Moines, Iowa Hair Loss Replacement - Restoration Center located in central Iowa and we are dedicated to serve our clients in Iowa, including the cities of Sioux City, Council Bluffs, Des Moines, Fort Dodge, Ames, Cedar Rapids, Iowa City, Davenport, Dubuque, Waterloo, Adel, Marshalltown, Pella, Decorah, Knoxville, Eldora, Johnston, Ankeny, and Burlington , and the communities that make up Woodbury, Pottawattamie, Polk, Webster, Story, Linn, Johnson, Scott, Dubuque, Black Hawk, Dallas, Marshall, Marion, Winneshiek, Madison, Hardin and Des Moines counties.
 
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