Free Hair Loss Evaluation

This evaluation will help us learn about your unique hair loss condition. This is the first step in developing a hair restoration solution that is right for you.

Please fill out the following form and we will begin your evaluation right away.

No matter your sex, hair loss can do more than take away your natural, youthful appearance. Hair loss is a condition that can reach into virtually every important aspect of your life, from work performance to personal relationships, and rob you of life’s joys.

Our goal at Abstrax is about much more than restoring your hair. We offer many individualized solutions, tailored to your unique hair loss condition, that not only make you look your very best, but make you feel your very best.

First and Last Name (required)

Phone Number (required)

Email Address

Address

City

State

Zip Code

How Would You Like To Be Contacted?
 Phone Email Postal

Would you like to enter our quarterly drawing for a FREE Abstrax treatment program for one year?
 Yes No

Your Age

Gender
 Male Female

Ethnicity/ Hair Type

What Best Describes Your Hair Loss Condition?

How long have you been experiencing hair loss?
 1-3 Years 4-7 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?
 Dandruff Itchy Scalp Dry Scalp Oily Scalp Excessive Shedding

Have you attempted to do anything about your hair loss situation?
 Rogaine/Propecia Hair Transplant Herbal Solution Hair Extensions Hair Systems Lotions/Shampoos Nothing

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?
 Home Life Work Life Social Life Dating Intimacy None

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 Abstrax Hair Designs?

Our goal at Abstrax

Its about much more than restoring your hair. We offer many individualized solutions, tailored to your unique hair loss condition, that not only make you look your very best, but make you feel your very best.