Hair Loss Evaluation

If you are interested in learning whether Low Level Laser Light Therapy is right for you, fill out the form below and one of our team members will reach out to you.

Besides experiencing hair loss, are you considered healthy?
YesNo


Are you currently undergoing cancer treatments?
YesNo


Are you currently in remission?
YesNo


Is your hair finer/thinner than it once was?
YesNo


How long have you been experiencing hair loss?
less than 6 months6 months to 1 year1 to 5 yearsMore than 5 years


Have you changed the way you style your hair to try to conceal hair thinning?
YesNo


Have you found more hair than normal on your pillow, brush or shower drain?
YesNo


If you tie a ponytail, is the circumference of the ponytail smaller than it was before?
YesNoDoesn't Apply


In the part down the middle of your scalp, does the width of the part show more scalp than normal?
YesNo


Have members of your immediate or extended family, male or female, experienced hair loss?
YesNo


Have you sought professional or other advice for your hair?
YesNo


Select which of the following treatment options, if any, you've considered for hair loss:
MinoxidilPropecia (Finasteride)Light therapyOther


Select which of the following treatment options, if any, you have undergone:
MinoxidilPropecia (Finasteride)Light therapyOther


Are you currently being treated for hair loss? If so, how long?
less than 6 months6 months to 1 year1 to 5 yearsMore than 5 yearsNo


*Name:


*Phone:


*Email:


Is there anything that we should know?

Please leave this field empty.