FREE ONLINE HAIR LOSS EVALUATION FOR WOMEN

By sending us this completed form you will enable hair4all to get to know your hair loss situation.

Privacy Policy

hair4all assures you that we take your right to privacy very seriously. We will only use this information internally to provide you with the best products and service. hair4all will not sell or reveal to any third party your personal information submitted to us.

Please can you provide the following information and answer all questions with as much information as possible.
Title (Miss, Mrs, Dr, etc):
First Name:
Last Name:
House Name/Number:
Street / Road Name:
Town:
City:
State (if applicable):
ZIP / Postal Code:
Country:
Phone Number:
Mobile / Cell Number:
Contact email:
Preferred Contact Method:
Preferred Contact Time (Your Local Time):

How did you hear about us, e.g. search engine, another site, etc?

Please indicate what pattern of hair loss you have using the diagram below?

If your hair loss is due to a medical condition such as Chemotherapy then please provide some further details:
What made you decide to do something about your hair loss (choose all that apply)? Looking older than your age Hate the way you look A wish to attract younger people Pressure at work to look younger Pressure from others Embarrassment Lack of confidence Socially unacceptable Depression Unattractive Less feminine Other (please give details)
What percentage of hair loss do you have?
How long have you been experiencing hair loss?
Have you experienced an increase in hair loss in the past year?
Do any of your immediate family members have hair loss (choose all that apply)? Father Mother Brother(s) Sister(s)
Is your scalp visible in the area(s) where you have lost hair?
Does your scalp flake?
Do you suffer from any of the following conditions (choose all that apply)? Dandruff Itchy Scalp Dry Scalp Oily Scalp Other (please give details)
What color is your hair?
What type of hair do you have (choose all that apply)? Mousey Defused Dry Textured Broken Fine Oily Thin Other (please give details)
How would you characterise the hair growing on the back and sides of your head?
Have you consulted a doctor or professional about your hair loss? If Yes, what was said?
What situations bother you most about your hair loss (choose all that apply)? Wind Rain Swimming Lights Work Nights Out The Look Other (please give details)
Do you perform any cover ups (choose all that apply)? Mane Spray Toppix Caps Hats Scarfs Blow Dry Hair Hair Spray Thickener Other (please give details)
How often do you think about your hair loss?
Do you feel your hair loss prohibits you from being who you really are?
Do you or have you used lotions/tablets for your hair loss (choose all that apply)? Rogaine Regain Hormone Replacement Propecia Herbal Vitamins Other (please give details)
Have you done anything else about your hair loss (choose all that apply)? Transplants Hair System Hair Piece Wig Toupee Hair Extensions Laser Therapy Other (please give details)
What procedure(s) / service(s) are you interested in (choose all that apply)? Custom Hair System Pre-Custom Hair System Full Head Bond Hair System Perimeter Bond Hair System Lace Front Hair System Hair Transplants Hair Extensions Hair Laser Therapy Hair Servicing Other (please give details)


What is your occupation and does it contribute to your hair loss concerns?
What are your hobbies and do they contribute to your hair loss concerns?
Are you ready to do something about your hair loss immediately?
Have you a regular stylist you go to that you would like to continue using the services of?
Would you like hair4all to find you a stylist in your area?
Please provide any other information you would like us tell us about your hair loss situation?

How did you hear about us, e.g. search engine, another site, etc?
What other hair replacement companies do you know of?
Is there any other information or questions you think might be useful to include in our Online Hair Loss Evaluation?

The following section should be completed only if you are an existing wearer of Hair Replacement Systems, Hair Pieces, Wigs, or Toupees.
How long have you been in hair replacement?
Do you purchase your hair replacement system and products from the internet?
What company or site do you purchase your hair replacement system and products from?
Do you use the services of a retail hair replacement centre?
What is the name of the hair replacement centre you use and where is it located?
What type of hair replacement system are you using at the moment?
If you know what hair is used in your existing hair replacement system then please provide details (e.g. human hair, synthetic hair, Asian Hair, European Hair, Remi Hair, etc)?
Are you on permanent adhesive bond?
How long does your hair replacement system bond for?
Do you clean and attach your hair replacement system yourself?
Does the hair color in your hair replacement system fade?
How much do you pay for your hair replacement system(s)?
If you are on a membership or subscription plan then how long is it before your renewal date?
What frustrates you the most about your current hair replacement system, hair replacement system provider, services, products, etc?

Thank You.