APPOINTMENT TYPE *

Which do you prefer?

In Person

VIrtual

NAME *

First Name

Last Name

BIRTHDATE *

Please enter your birthday

MM

DD

YYYY

ADDRESS *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

PHONE *

Your main contact phone number

(###)

###

####

ALTERNATE PHONE NUMBER

Please enter a 10-digit alternate phone number

(###)

###

####

SELECT THE ACTIVITIES YOU PARTICIPATE IN:

Please select all the activities that apply

Basketball

Baseball

Watersports

Tennis

Golf

Weightlifting

Running

Biking

Soccer

Hiking

Fitness/Yoga

HOW HAS HAIR LOSS AFFECTED YOUR LIFESTYLE?

Select all that apply:

Meeting new people

Self Esteem

At the Beach

At Work

When others comment

In my social life

Overall appearance

When I wear a hat

On a windy day

Seeing old friends

Getting dressed up

When playing sports

WHAT REMEDIES HAVE YOU TRIED? *

Select all that apply:

Shampoo

Hair Piece

Hair Transplant

Rogain-Minoxidal

Propecia

Nothing