Finding your risk for hairloss could save your hair: Take the first genetic test for the hairloss gene.



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Freedom Hair Systems Contact Form

We will be happy to provide you with a detailed analysis of your situation. Simply complete the fields below and our patient education specialist will go over your information and provide helpful feedback on your road to restoring your hair. All information supplied will be held in the strictest confidence. Thank you for your cooperation in completing this contact form.
Name:  *
Phone:  *
Email:  *
Address:
City:
State:
Zip:
Date of Birth:

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 hairloss occured?
(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 and full thick and full thin and slightly receding

7. Does your scalp excrete excessive sebum (oils)?
Yes No

8. Have you ever experienced a build-up of sebum (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 hairloss in the past year?
Yes No

13. Have you ever tried to do anything about your hairloss?
Rogaine Hair Transplant Hair Replacement Lotions/Shampoos Nothing

14. Have you ever seen a doctor about your hair loss?
Yes No

15. Has anyone ever mentioned your hairloss to you?
Wife Girlfriend Husband Boyfriend Mother Father Other

16. Does that bother you?
Yes No

17. Why do you want to do anything about your hair?
I look older than I feel I hate the way my hair looks I want to meet younger men/women
People make fun of me

18. Do you want to:
Stop your hairloss? Have more hair?

When you are ready to submit the above information just click on the button below.
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