Boost Your Confidence. Hair Replacement Pre-Consultation Survey
Ready for change? Complete this survey to kickstart your confidence
First Name
*
Last Name
*
Email
*
Phone
*
PC-S What kind of hair loss do you have
*
Receding
At the Crown
Patchy Baldness
All Over
PC-S How prominent is your hair loss in that area
*
A little (Only I notice it)
Some (Those close to me notice it)
A lot (Its obvious to everyone)
Which of the following best describes your hair type
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Straight
Curly
Afro/Kinky
Other
PC-S When would you prefer to have the service done?
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ASAP
In the next 1-2 weeks
Within the next 30 days
In the near future, no rush
Whats the best number to contact you on?
*