(551) 212-8805

Take a Hair Questionnaire

Hair Survey

1. Your Information

FIRST NAME *

LAST NAME *

PHONE

EMAIL *

DATE OF BIRTH

STREET ADDRESS

ADDRESS LINE 2

CITY

STATE

ZIP

2. Hair / Health Profile

WHEN DID YOU FIRST NOTICE YOU WERE LOSING HAIR?

HAVE YOU EVER USED ROGAINE

HAVE YOU EVER BEEN PRESCRIBED AND USED PROPECIA?

DO YOU TAKE ANY MEDICATIONS ?

DO YOU HAVE ANY EXISTING MEDICAL CONDITIONS OR ILLNESSES?

DO YOU SMOKE?

HAVE YOU HAD A HAIR SURGERY IN THE PAST?

TELL US ABOUT HAIR LOSS ON YOUR MOTHER'S SIDE OF YOUR FAMILY.

TELL US ABOUT ANY HAIR LOSS EXPERIENCED BY YOUR BROTHERS OR SISTERS.

3. Your Hair Procedure

SELECT THE AREAS OF YOUR SCALP WHERE YOU NEED HAIR RESTORATION

Front

Top

Small Crown

Expanded Crown

4. Upload your photos

Front Photo

Maximum upload size: 1MB

Top Photo

Maximum upload size: 1MB

Left Photo

Maximum upload size: 1MB

Right Photo

Maximum upload size: 1MB

Back Photo

Maximum upload size: 1MB

By submitting this form you agree to receive SMS from Rapaport Hair Institute Carrier and Data rates may apply. Message frequency may vary Reply STOP at any time to end messaging or Reply Help for more information.

REQUEST YOUR
CONSULTATION