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Hair Loss Evaluation Form

First and Last Name

E-mail Address: (Required)*

Phone Number: (Required)*

Postal Address: (Required)*

How would you like to be contacted?

Phone

Postal

Date of Birth:

Gender:

Male

Female

Type of Hair and Ethnicity:

Which Volumize Ireland 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

Do you suffer from any of the following conditions? Note: To select more than one choice, hold down the "Ctrl" key. Choose all that apply.

Have you attempted to do anything about your hair loss situation? Note: To select more than one choice, hold down the "Ctrl" key. Choose all that apply.

Have you consulted a doctor or other professional about your hair loss?

Yes

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

Do you feel that your hair loss prohibits you from being "who you really are"?

Yes

Do you feel that your hair loss adversely effects your self-confidence?

Yes

Do you feel that your hair loss adversely effects your self-esteem?

Yes

In which areas of your life do you feel your hair loss adversely impacts you? Note: To select more than one choice, hold down the "Ctrl" key. Choose all that apply.

How do you feel Volumize Ireland can best serve you?

Are you ready to do something about your hair loss immediately?

Yes

Please offer us any additional information and/or comments regarding your hair loss:

How did you become aware of Volumize Ireland?*

If you chose "Other", please specify:

If possible, please upload and send a photo of your hair loss to Volumize Ireland : Extensions: jpg,jpeg

If possible, please upload and send a second photo of your hair loss to Volumize Ireland : Extensions: jpg,jpeg

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Hair Loss Evaluation Form