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Ready to stop hair loss and regrow lost hair?

Submit your 5-minute assessment to evaluate your hair growth potential.

It’s simple and FREE and we never sell your info to anyone!

Hair loss contributors must be identified & effectively combatted for successful hair regrowth to occur.

The latest technology in the ongoing hair loss battle: The Trichology Assessment

  • Developed by hair transplant surgeons and certified trichologists
  • Your assessment will uncover hair loss contributors
  • Your assessment will evaluate your hair growth potential
  • Your assessment will provide an effective plan for hair recovery

Hair loss can be caused by various contributors and without effective intervention, it will simply get worse.

Please be as accurate as possible in providing your answers as they will determine the accuracy of your final report.

ALL questions are mandatory for your assessment.

    This is to make sure we ask the right questions.


    Date*




    YesNoUnknown

    Have you had any surgery within the last year with General Anesthesia? *
    YesNo

    Do you have any of the following medical problems?

    Irregular Heartbeat *
    YesNo

    Do you take medication to control this condition?

    Coronary Artery Disease:*

    Do you take medication to control this condition?*

    Congestive Heart Failure *


    Depression*

    Stroke*

    Adrenal Hyperplasia *

    Date of last physical *

    Stress Level *

    Have you ever had a scalp biopsy? A scalp biopsy is when a physician removes of a small portion of scalp from the patient’s head which is then sent to a lab for testing. *

    Was a diagnosis made?




    CBC (Complete Blood Count)*

    Hormone: DHEA/Testosterone/Estrogen *

    Thyroid Panel: *

    Glucose: *

    Vitamin D: *

    Was Vitamin D in a normal range? *

    Iron: *

    Was it in a normal range?

    Have you ever been diagnosed with any type of Anemia?






























































    Check all that apply.













    We do not agree to work with everyone because not everyone is a good candidate for what we offer. To determine if you are a good candidate, let us know your answer to the following:




    1000



    Write your full name to sign.


    ATTENTION: Before you submit, please add [email protected] to your contacts and whitelist to prevent your customized report from going into your spam folder.