HAIR LOSS EVALUATION FORM

Begin your journey toward a natural, thicker, more youthful head of hair. Complete the form below to help our hair restoration experts determine if laser therapy is right for you.

Your Privacy is Important to Us. Your answers will be confidentially reviewed by Capillus® to determine if low level laser therapy is suitable for you. For immediate assistance, call 1-786-888-6249 or email us. Your privacy and security are our top priorities. For more information, review our Privacy Policy.

We need to know a little bit about you & how you want to be reached...

ADDRESS

Now we need a little history on your hair health

Is your hair finer or thinner than it once was?


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


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


If you tie a ponytail, is the circumference of the ponytail smaller than it was before?


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


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


Have you sought professional or other advice for your hair?


Select which of the following treatment options, if any, you've considered for hair loss





Select which of the following treatment options, if any, you have undergone.





Otherwise healthy