Birth Control
Hair Loss Assessment
9 Out of 10 People
Who Take This HAIR LOSS ASSESSMENT
Find The Solution To Their Hair Loss!
1. How long have you been on birth control?
*
Less than 1 year
2-5 years
5-10 years
More than 10 years
2. Have you taken or used in the past 5 yrs. any of the birth control listed below?
*
Yaz or Yazmine
Mirena or any other IUD
Ortho Tri-Cyclen or Lo Loestrin
Other
3. How many times have you switched the brand of your birth control in the past 5 years?
*
None
1 time
2 times
3 or more times
4. How many times have you gone ON and OFF birth control in the past 5 years?
*
None
1 time
2 times
3 or more
5. How old are you?
*
Less than 21
21 to 45
45 to 55
55+
6. How long have you been losing hair or thinning?
*
Less than 1 year
2 to 5 years
5 to 10 years
10+ years
7. Does anyone else in your family suffer from hair loss or thinning hair?
*
Yes
No
8. Do you take any other medication that require a doctor's prescription other than birth control?
*
Yes
No
9. Have you had any weight loss or weight gains of 10 pounds or more in the past 12 months?
*
Yes
No
10. Have you suffered any life altering events that can be classified as “traumatic” in the past 5 years?
*
Yes
No
First name
*
Last Name
*
Email
*
Phone
*
Please describe your hair loss issue
*
Before we begin your Hair Loss Assessment, please check the box below acknowledging that in order to protect your Privacy the results of your assessment WILL NOT be shared through Email or Text.
*
YES, I wish to receive a call from the Hair Loss Specialist to discuss my results.
Best Time To Call
*
Morning
Afternoon
Eveninig
*Disclaimer: This is a general and preliminary assessment. An In-person Consultation and Scalp examination is necessary for a full treatment recommendation.
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