What kind of hair loss are you experiencing?

1. How long have you been losing your hair?
1-3 years 3-7 years 7-15 years More than 15 years

2. Gender:
Male Female  

3. How would you rate your current rate of hair loss?
Light Moderate Heavy

4. Have you experienced an increase in your rate of hair loss in the past year?
Yes No

5. Have you ever tried to do anything about your hair loss?
Rogaine Hair Transplant Wigs/Toupees/Hair Pieces
Lotions/Shampoos Nothing

6. Comments/Questions:

7.  Schedule an appointment (optional):

     We will be happy to schedule an appointment for you if you wish.
     Just suggest an ideal date and time and we'll contact you to
     confirm.

PLEASE NOTE:  If you experience any difficulties using this form, please email us at info@transitionsindy.com.