Ask the
Doctor

Let Us Contact You

Receive Free “The Do’s and Don’ts of Hair Loss”

Live Online Help

Click Here
to Chat Live


Contact us for Special Offer

Please contact us so we can find a sollution that will work for you!

Name *

First Name

Last Name
Email Address *

Email
Phone Number*
-
(###)
-
###

####
Address *

Stree Address

Appartment or Suite

City

State

Postal Code
How would you like to be contacted?

Phone

E-mail

Mail
Would you like to enter our quarterly drawing for a FREE Hair Loss treatment for one year?

Yes

No
Date of Birth

Year
Gender

Male

female
Type of Hair and Ethnicity
Which Treatment Method are you most interested in ?
What best describes your hair loss condition ?
How long have you been experiencing hair loss ?

1-3 Years

3-7 Years

7- Years 15yrs
Is your scalp visible in the area where you have lost your hair ?

Yes

No
Do you suffer from any of the following conditions?





Excessive Shedding

Have you attempted to do anything about your hair loss situation?

Rogain








Have you consulted a doctor or other professional about your hair loss ?

Yes

No
How often do you think about your hair loss situation ?

Some Times

Often

All the time
Does your hair loss situation ever make you feel depressed ?

Yes

No
Do you feel that your hair loss prohibits you from being "who you really are" ?

Yes

No
Do you feel that your hair loss adversely affects your self-confidence ?

Yes

No
Do you feel that your hair loss adversely affects your self-esteem ?

Yes

No
In which areas of your life do you feel your hair loss adversely impacts you ?




Dating
Intimacy

What are your hair loss goals for your HLCC Treatment ?
Are you ready to do something about your hair loss ?

Yes

No
Please offer us any additional information and/or comments regarding your hair loss
How did you become aware of Hair Loss Control Clinic ?
Are you aware that HLCC has been in business since 1987, has 3 doctors and provides unique treatment programs to consumers, doctors and hundreds of clinics worldwide ?

Yes

No
*Verification
(Complete the simple equation below)
+ =
If possible, please upload and send a photo of your hair loss to HLCC a Medical Doctor or specially trained RN will review it