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If you are losing your hair, or if somebody in your family has lost their hair, and you would like to find out if you are headed in the same direction, please complete the confidential questionnaire below. An examination of your hair and scalp under magnification can help determine the causes of your thinning hair and if you are likely to have more hair loss in the future. It can also help determine the feasibility of using topical treatments and low level laser light to stimulate hair growth. Your hair loss analysis will be conducted in complete privacy and may include microscopic analysis, strand tests, and genetic testing. To book your hair loss analysis, please complete the form below or feel free to call us at 416-512-6400.
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Full Name: |
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Address1: |
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Address2: |
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Postal Code: |
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Email: |
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Phone: |
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When is the best time to
contact you? |
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What is your age? |
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Gender: |
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How much hair have you lost?
Please indicate which picture resembles your hairloss
the most.
Norwood Grade: (Click to
view grades)
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| How long have you been losing hair?
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Has anyone in your family shown signs of hair loss?
(Choose all that apply)
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Have you ever done anything about your hair loss?
(Choose all that apply) |
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Please choose the best day for your appointment:
(allow 45 minutes)
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Please choose the best time for your appointment:
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| Please add any questions, concerns or comments.
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Privacy Statement: The personal inforation collected here is for Freedom Hair System's
professional consultants in order to help determine your eligablity for the free
trial promotion. This information will not be sold or given out to anyone without
prior permission of the submitter. Freedom Hair Systems keeps it's clients in touch
with the latest discoveries, important developments and special promotions in the
hair loss and hair replacement areas through our newsletter: "The Hair News".
To opt out of receiving "The Hair News", please click the following button:
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