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CONTACT HAIR RESTORATION CENTERS

Please fill out this form to learn more about treating your hair loss and your options with hair transplants or alternative treatments. You can also submit to us your hair loss photos which will give us a better understanding of your hair loss and an approximate idea of your hair replacement needs. One of our doctors will review your photos and provide you with an evaluation and recommendation.

Your information and photos become a part of your medical file at HRC and we will not sell, trade, lease or give that information to anyone – ever. If you have more questions, comments or helpful information to give us after you have completed this form, please do not hesitate to contact us again. An asterisk (*) indicates a required field.

    Your Name (required)

    Address

    City

    State

    Zip

    Phone

    Best time to call

    Email(required)

    Personal / Health Information

    Age

    Gender
    malefemale

    Please list any existing medical conditions or allergies

    Any family history of baldness or thinning hair?(required)

    Did baldness or thinning hair come about rather suddenly?(required)

    What is your time frame to proceed?(required)

    Will you require financial assistance?(required)

    Please include any additional information, concerns or questions that will help us to better fulfill your request

      Start Your Consult Here or call (800) 510-3386 text (800) 315-0768