Hair Loss Survey - Exclusive Experience Company

For A Quick Consultation

Disclaimer: We do not sell or use your information for any purpose other than assessing hair loss

Get tailored recommendations for effective hair loss treatments.

The survey will help us understand your hair loss and concerns so that we can create a treatment plan that’s best for you.

Step 1 of 8

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1. How long have you been experiencing hair loss?(Required)

0-2 Years

3-5 Years

6-10 Years

10+ Years

2. Hair loss affects people of all ages. When did you start experiencing hair loss?(Required)

Below 20 Years Old

Between 20-30 Years Old

Between 31-40 Years Old

Between 41-50 Years Old

Above 50 Years Old

3. What is the cause of your hair loss (if known)? Select all that apply.(Required)

Hereditary (Hair loss runs in my family)

Medical conditions (such as Cancer, scalp infections or alopecia)

Medications

Stress or traumatic events

Unknown

4. Which areas of your hair loss are most concerning to you? Select all that apply.(Required)

Receding hairline

Thinning crown or top of the scalp

General hair thinning

Bald spots (such as alopecia)

Scaring (caused by traumatic events or hair transplant)

Completely bald or shaved head

5. How has hair loss affected your self-esteem and confidence?(Required)

Significantly affected my self-esteem and confidence

Somewhat affected my self-esteem and confidence

Does not affect my self-esteem and confidence

6. Have you tried any hair restoration treatments before? Select all that apply.(Required)

Hair transplants

PRP (Platelet Rich Plasma) therapy

Laser therapy

Topical treatments (such as creams, shampoos, oils or minoxidil)

Other

No, I have not tried hair restoration treatments before

7. On a scale of 1-10, how concerned are you about your hair loss? 1 being not concerned at all and 10 being extremely concerned.

8. Interested in learning more about effective hair restoration treatments that can help alleviate your hair loss? Enter your contact details below and we will send you more information.(Required)

First Name Last Name

Phone(Required)

Email(Required)

Added Bonus: Complete the survey to get a Hair Loss Evaluation Today! ($99 value)

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1042 Camellia Blvd. Suite 3 Lafayette, LA 70508
(337) 345-8251
[email protected]

OPENING HOURS

Monday: Closed
Tuesday-Saturday
7:00 AM - 7:00 PM
Sunday : Closed

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