Online Assessment Form

Don't Worry, We Will Find The Solution!

Let's Gather A Few Details About Your Situation To Know If You Are A Good Fit For Our Program. We Will Assess This Information, Review It With You At Your Scheduled Consultation, Then Develop Your Individualized Treatment Plan After Reviewing Your Scalp & Performing A Diagnostic Test To Verify Your Bodies Wellness Deficiencies. Our Goal Is To Provide You The Right Program To Get You Started On Your Road To Recovering Your Healthy Hair & Maintaining It After Our Program.
Before You Get Started - Please Take Photos of Your Scalp or Problem Areas.

They Are Required For The Assessment To Be Completed Properly.
What Is Your Name?*

FirstMiddleLast
Cell Phone Number*
Format: (000) 000-0000.
Email*
example@example.com
What Is Your Birth Date?*

MonthDayYear
Type It In
Google SearchCustomer ReferralStylist RecommendationOur Website AdvertisementSocial MediaOther
Current Address (This is only used for shipping products to you if required.)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What Is Your Current Height?
* feet
* inches.
What Is Your Current Weight?*
In lbs. (Approximate) - Ex: 165
ABI Don't Know ItOABI would like a blood test done At My Appointment - $25 Add On Fee
YesNo
Please List Any Allergies You May Have or Have Been Diagnosed With. This Is Important For Providing The Correct Treatment With Your Individualized Program. *
Please List Any Illnesses or Conditions You Have Been Diagnosed With. This Is Important For Providing The Correct Treatment With Your Individualized Program. *
PCOS (Poly Cystic Ovarian Syndrome)EndometriosisAnemiaNo Current ConditionsOther
No Current Scalp ConditionsPsoriasis (Can Also Affect Your Eyebrows)Eczema (On the body or scalp)Seborrhea DermatitisDandruffOther
(Only) My Edges(Only) My Middle Part Part Area; Is Getting Wider(Only) My Crown Area; On The Top of My Head Is ThinningBoth; My Front Hairline & Crown Are ThinningMy Hair Is Breaking OffI Have Excessive SheddingMy Hair Is Growing Out, But It Looks ThinnerMy Hair Is No Longer GrowingOther
How Long Ago Did This Issue For You Begin?*
What Was Going On When You Noticed The Hair Loss?*
What Is Your Main Concerns Dealing With Hair Loss?*
AnxietyBirth ControlMenopause / Hormone Replacement TherapyGastro Issues / IBS / Constipation / Acid RefluxDiabetesHigh Blood PressureThyroidOther
Yes - MenYes - WomenBoth SidesNo - MenNo - Women
YesNo
YesNo
Life Stressors (Work, Home, Personal or Relationship Related)Had A BabyHospitalization / Surgical ProcedureWeight Loss Diet or ProcedureNo
YesNo
NoYesI am Around 2nd Hand Smoke
Scalp Condition - YesScalp Condition - NoThe Scalp Condition Treatment Was Not SuccessfulHair Loss Treatment - YesHair Loss Treatment - NoThe Hair Loss Treatment Was Not Successful
Where You Previously Diagnosed With A "Type" of Hair Loss By A Dermetologist or Doctor? *
Hair Growth Oils/ Creams / GelsHair Growth VitaminsHair Growth ShampoosInjectionsLLLT - Low Level Laser TherapyPRP - Platelet Rich PlasmaRogain - RX or OTCOther
Level 1Level 2Level 3Level 4Level 5Level 6Level 7Level 8Other
Please Upload A Photo of - Your Front Hairline*

Browse Files

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Please Upload A Photo of - The Top of Your Head*

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Please Upload Any Additional Photos *

Browse Files

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MondaysTuesdaysWednesdaysThursdaysFridaysSaturdaySundaysMornings (9a-12p)Afternoons (1p-4p)Evenings (5p-7p)
YesNo
How Soon Are You Looking To Get Started Reversing Your Hair Loss?*
GeorgiaFloridaOther
CashCredit CardACH / No Credit Check OptionsSimple FInancing for 12 Months or Longer
Thank You For Completing Your Online Assessment Today!

The Next Thing To Do Is...

Get You Scheduled For Your

Assessment Screening Appointment ASAP!

Also, Don't Forget You Can Get Prequalified Today With Our Financing Program

To Start Your Program Today!

No Hard Credit Check - No Hideen Costs or Fees - Flexible Payment Options

Use The Link On The Thank You Page.
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Don't Worry, We Will Find The Solution!

Before You Get Started - Please Take Photos of Your Scalp or Problem Areas.