hair loss solutions...request.html

To receive your personalized Free Consultation (a special offer for our Internet clients), please complete the questionaire and click the "SUBMIT" button. We may contact you for additional information if necessary. Otherwise, you will receive our detailed consultation and professional suggestions along with our trial offer with limited money back guarantee. You may also contact us personally by email at wrwellman@comcast.net.

Your Name:
Address:
City:
State:
Zip:
E-mail:
Phone Number:

Age:
Race:
Sex:

Type of Hair:
How long has your hair been thinning:
Hair fall recently:
Scalp Condition - A:
Scalp Condition - B:
Any indication of scalp disease:
Open abrasions on scalp:
Family history of baldness or thinning:

General Health:
Under doctor's care at present:
Serious illness:
Prescription medications:
Diet:
Stress level:
Exercise regularly:
Do you take vitamins regularly:
	Type:

How often do you shampoo:
Do you use conditioner:
Do you:
Do you use dressings, hair spray, mousse, gel, oil, grease, etc.:
	Frequency:
Any chemicals used, such as perms, dyes, bleach, relaxer, curl, etc.:
	Frequency:
Do you wear wigs, hats, night cover, etc.:
	Frequency:

Please describe your problem briefly:
Other comments: