PERSONAL CONSULTATION

We can determine the hair loss solution that is right for you.
For a personalized service, call an associate at 1-800-533-0866.
For a virtual consultation, fill out the form below and one of our associates will contact you.

Last Name
First Name
Address
City
State		Zip
Phone
Alternate Phone
Email
Occupation
Age Range	Select Here 18-24 25-34 35-44 45-54 55-64 65 +
Martial Status	Select Here Single Engaged Married Separated Divorced
Birth date

How did you hear about Another Look Hair Institute?
Have you received our brochure and product information? If so, how long ago?
Your hair loss was noticed at what age?
Does baldness run in your family? If so, who in your family has hair loss?
Are you aware of any scalp disorders you may have?
Are you currently taking any medications? If so, please explain.
What attracted you to Another Look Hair Institute?
What are your concerns about restoring your hair?

What activities do you participate in?
		Basketball		Baseball		Football
		Water Sports		Tennis		Golf
		Weight Lifting		Running		Other, please specify:
		Biking		Soccer
Please indicate how your hair loss affects your lifestyle.
		Meeting New People		When others comment		On a windy day
		At the Beach		In your social life		Seeing old friends
		Self-esteem		Overall appearance		Getting dressed-up
		At work		To wear a hat		When playing sports
What have you tried?
		Shampoo		Hair Piece		Hair Transplants
		Rogain-Minoxidal		Propecia		Nothing
		Other, please specify
Please indicate which number best describes your hair loss from the diagrams below:
Once you hit submit, your information will be sent to us and an associate will be in touch.

 

1020 East Saginaw
Lansing, Michigan 48906
1-800-533-0866

© Copyright 2006 Another Look Hair Institute.