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Free consultation form for women

Women free consultationThis consultation form is a chance for you to get in touch with a Hairfax International consultant. Simply fill out this form for an interactive and free consultation.

Consultation form for men, click here

 

* All fields marked with an asterisk are required.

First name :
*
Last name :
*
Address :
City :
*
Province :
Zip Code :
Phone :
Home *
Office
Other
Email :
*
Age :

Specific information

  
For how long have you been losing your hair?
Do you think that your hair loss is genetic? Yes No
Hair color:
Scalp condition:
Hair Texture:
Hair Nature:
Hair length:
 cm
Itching:
 Yes No
On a scale of 1 to 10, how important for you is the reconstitution of your hair?

01 02 03 04 05

06 07 08 09 10

According to the chart below, what image best represents the current state of the loss of your hair?
Women Hair Loss Type A Women Hair Loss Type D Women Hair Loss Type G  
Women Hair Loss Type J Women Hair Loss Type E    

Additional information, questions, comments.

Would you prefer to be contacted by telephone or email?
email phone