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Candidate Quiz
Name
(Required)
First Name
Last Name
Email Address
(Required)
Phone Number
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Location
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Ohio
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Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
I am ___ years of age
(Required)
- Please choose an option -
20 - 30 years old
30 - 40 years old
40 - 50 years old
50 - 60 years old
60 - 70 years old
70+ years old
How did you hear about us?
(Required)
- Please choose an option -
Google
Social Media
TV Commercial
Friends/Family/Referring Physician
Email Newsletter
Flyer/Brochure/Business Card
I have been thinking about hair restoration for ___
(Required)
- Please choose an option -
Under a year
1 - 3 years
3 - 6 years
6+ years
The areas that bother me the most include:
(Required)
The Hairline
The Crown
The Mid-portion or Vertex
The Temples
My Eyebrows
My Facial Hair
My biggest concerns when considering a hair restoration procedure are:
(Required)
Pain
Cost
Downtime
Nervous about outcome
My age
Infection
Scarring
The face that people may notice
My main reason for considering a Hair Transplant is:
(Required)
- Please choose an option -
I want to look younger and/or refreshed
I have a special event that I would like to prepare for
I want to feel better about myself and my appearance
A significant other or other influential person is a factor in my decision
I've had a major life event which has motivated me
Other
I would describe myself as a happy person:
(Required)
Strong Disagree
Disagree
Neutral
Agree
Strongly Agree
I would describe myself as someone with realistic expectations:
(Required)
Strong Disagree
Disagree
Neutral
Agree
Strongly Agree
I am satisfied with how I look in the mirror today:
(Required)
Strong Disagree
Disagree
Neutral
Agree
Strongly Agree
I would say that I have done my research and have a lot of knowledge regarding hair restoration:
(Required)
Strong Disagree
Disagree
Neutral
Agree
Strongly Agree
I am serious about having this procedure within:
(Required)
- Please choose an option -
6 months
6 months - 1 year
Over 1 year
I'm just looking for information
I have tried:
(Required)
Medications
Special Shampoos/Conditioners/Hair Treatment
Hair Vitamins/Supplements
Laser Caps/Combs
Alternative Treatments
Hair Pieces/Wigs/Hair Camouflage Products
Previous Hair Transportation
How would you like to be contacted?
(Required)
- Please choose an option -
Phone
Email
Terms of Use
(Required)
I consent
By checking this box, I consent to the
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