AnneMichelle Hair Solutions + Scalp Studio

1. How did you hear about AnneMichelle Hair?

Online search
From a friend
Drove By
Other

If other

2. What best describes the reason you visited us today?

Learn about AnneMichelle Hair Solutions
Research Options
Schedule an appointment
Pricing

3. How long have you been experiencing hair loss?

3. How old are you?

4. What is your gender:

5. Would you say that your hair loss is:

Just starting
Actively falling out/Shedding profusely
Slowing down but still shedding
Seems to have plateaued and maintaining
I am bald
Not sure

6. Are you currently experiencing: please check all that apply

Hair Fall/Shedding/Loss
Hair Breakage
Oily Scalp
Itchy Scalp
Sore Scalp
Dry Scalp
Flaky Scalp
None of the above
Other

If Other, please describe

7. Have you ever been diagnosed with a medical condition or had a trauma that could be related to your hair loss?

What was your diagnosis/trauma?

8. Has your hair loss been medically diagnosed?

What was your diagnosis?

9. Are you currently taking any prescription medications? (this could affect your hair loss)

10. Do you have any blood relatives that have hair loss?

11. Have you ever worn or considered a hair replacement system before?

12. What area(s) is/are of most concern? (check all that apply)

Hairline/Frontal Area
Temples
Mid-Scalp Section (highest part of the round of the head)
Crown Area (right behind the mid-scalp area)
Other

If Other, please describe

13. How has hair loss affected your life?

14. What are your hair and scalp goals? Your hair hopes and dreams?

15. You are interested in learning about: (check all that apply)

If Other, please describe

Additional comments:

Check here if you are just information gathering and email contact is sufficient for now.
Check here if you would like to receive a follow-up phone call from AnneMichelle Hair because you are ready to make great strides in your hair loss solution journey.

Thank you for completing the hair loss test. Your results will be emailed to you. We know you are very busy during these crazy days and we want to respect your valuable time, so would you kindly let us know how you would like to receive communication from us.

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Hair Loss Test

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Hair Loss Test

Our Address

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