Q1. What’s your age group?
Under 25
25–34
35–44
45–54
55+
Q2. Where are you noticing hair loss the most?
Hairline / Forehead
Crown / Top of Head
Thinning All Over
Patchy Bald Spots
Q3. How long have you been experiencing hair loss?
Less than 1 year
1–3 years
3–5 years
5+ years
Q4. Have you tried any treatments before?
Over-the-counter shampoos/medications
PRP or Stem Cell Therapy
Hair Transplant
None
Q6. What’s your gender?
Male
Female
Prefer not to say
Q8. Have you had any major health issues in the last 12 months?
Yes
No
If yes, please list any health concerns (optional)
Q9. What’s your biggest goal with hair restoration?
Tell us in a sentence what matters most to you (confidence, youthful look, career, dating, etc.)
If you’re eligible, how soon are you considering treatment?
Within 1–3 months
3–6 months
Just exploring for now
Q10. Best way to reach you with your results?
Full Name
Email
*
Phone
*