Comprehensive Evaluation

Tell us About Your Hairloss

We have developed this comprehensive evaluation to learn more about your unique hair loss condition. This evaluation represents a first important step toward developing a Corrective Hair Solution that is right for you.

Please fill out the following form and submit it to us for evaluation by a member of our professional staff.

Whether you are a man or a women, hair Loss can do more than take away your natural, youthful appearance. It can rob you of life's pleasures. Hair Loss is a condition that can reach into virtually every important aspect of your life, from work performance to personal relationships and more.

The goal of Corrective Hair Solutions (CHS) is about much more than restoring your hair. CHS represents a myriad of individualized solutions - customized to your unique hair loss condition - that not only makes you look your very best but makes you feel your very best.

First and Last Name:
E-mail Address:
Phone Number:
Address:
City:
State/Province:
Zip/Postal Code:
Country:
How would you like to be contacted?
 Phone Email Postal
Would you like to enter our quarterly drawing for a FREE CHS treatment program for one year?
 Yes No
Date of Birth:
 19
Gender:
 Male Female
Type of Hair and Ethnicity:
What best describes your hair loss condition?
How long have you been experiencing hair loss?
 1-3 Years 3-7 Years 7-15 Years
Is your scalp visible in the area where you have lost your hair?
 Yes No
Do you suffer from any of the following conditions?
(Choose all that apply)
  
(Use CTRL-click to select multiple)
Have you attempted to do anything about your hair loss situation?
(Choose all that apply)
  
(Use CTRL-click to select multiple)
Have you consulted a doctor or other professional about your hair loss?
 Yes No
How often do you think about your hair loss situation?
Not much Sometimes All the time
Does your hair loss situation ever make you feel depressed?
Yes No
Do you feel that your hair loss prohibits you from being "who you really are"?
 Yes No
Do you feel that your hair loss adversely affects your self-confidence?
 Yes No
Do you feel that your hair loss adversely affects your self-esteem?
 Yes No
In which areas of your life do you feel your hair loss adversely impacts you?
(Choose all that apply)
(Use CTRL-click to select multiple)
Are you ready to do something about your hair loss immediately?
 Yes No
Please offer us any additional information and/or comments regarding your hair loss:
How did you hear about Corrective Hair Solutions? (Required)
If you chose "Other", please specify: