INTEGRATED HAIR SOLUTIONS

Hair Replacement Solutions for Women and Men

Free Hair Loss Evaluation

Please fill out the following form and submit it to us for your FREE (no-obligation) , private
and confidential hair loss evaluation by a member of our professional and courteous staff. Enter to win a free hair loss treatment !

First and Last Name: (Required)
E-mail Address: (Required)
Phone Number:
Address:
How would you like to be contacted?	Phone Email Postal
Would you like to enter our quarterly drawing for a FREE Hair Loss treatment for one year?	Yes No
Date of Birth:	19
Gender:	Male Female
Type of Hair and Ethnicity:
Which Integrated Hair Solutions Treatment Method are you most interested in?
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 mutiple)
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 effects your self-confidence?	Yes No
Do you feel that your hair loss adversely effects 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)
How do you feel Integrated Hair Solutions can best serve you?
Are you ready to do something about your hair loss immediately?	Yes No
Please enter any additional information and/or comments regarding your hair loss: