‘Take 2 Minutes To Complete This Form To Apply To Work With Dr. Vikram & Save Your Hair’

Click the image below that best represents your stage of hair loss:

I

II

III

III V

IV

V

VI

VII

How long have you been experiencing noticeable hair loss?

Less than 6 months

6 months to 2 years

More than 2 years

What other treatments have you already tried for your hair loss? (Select all that apply)

Over-the-counter remedies (e.g., minoxidil)

Prescription medications

Derma-rolling

Natural remedies

Laser therapy

None

What is most important to you for your hair restoration treatment plan? (Select all that apply)

Stop my hair loss from getting any worse ASAP

Boost my confidence and self-image for dating, work and other areas of life

Grow new hair and fix my hairline

Understand more about hair transplants

Make sure my hairline looks natural

Timing is extremely important when it comes to managing hair loss and hair restoration. Are you willing to act now if it means you could reach your goal stated above?

Yes

No

Is there anything else you think Dr.Vikram should know about your hair loss journey?

I understand that this is a $150 paid consultation with Dr. Vikram, and that if I choose to go ahead with the treatment plan with Atlantis Medical my consultation fee will be fully deducted from my treatment plan.

Last Step!

Enter Your Information Below to See If You Qualify.

I agree to the terms & conditions provided by Atlantis Medical. By providing my phone number, I agree to receive text messages from Atlantis Medical.

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