Virtual consultation form for men The information collected in the personal consultation form will allows us to have a detailed review with a PAI Medical Group hair consultant. Simply fill out this form and send it to us for a free, interactive consultation. Consultation for women Consultations Hommes Eng Personal information First name: * Last name: * Address: * City: * Province : * Postal code: * Phone: * Email: * Age Specific info For how long have you been losing your hair? For how long have you been losing your hair?1 month2 months3 months6 months1 year2 years3 years4 years5 yearsmore than 5 yearsmore than 10 years Do you think that your hair loss is genetic? Yes No Hair color: Hair color:BlondChestnutBrownBlackRedheadgray with 0 to 40% whitegray with 40 to 80% whitegray with 80 to 100% white Scalp condition: Scalp condition:NormalOilyDryDandruffOily + DandruffDry + Dandruff Hair Texture: Hair Texture:ThinMediumStrong Hair Nature: Hair Nature:StraightSoftWavyCurlyFrizzy Hair length: Hair length:0-5 cm5-10 cm10-15 cm15-20 cm+20 cm Itching:: Yes No On a scale of 1 to 10, how important is it for you to regain your hair? 1 2 3 4 5 6 7 8 9 10 According to the chart below, which image best represents the current state of your hair loss? logo required delete move drag clear noclear duplicate copy clone tooltip tooltip_solid forbid checkmark image checkmark circle checkmark square check check1 plus plus1 plus2 plus3 plus4 minus minus1 minus2 minus3 minus4 cancel cancel1 close report_problem_solid report_problem arrowup arrowup1 arrowup2 arrowup3 arrowup4 arrowup5 arrowup5_solid arrowup7 arrowup6 arrowdown arrowdown1 arrowdown2 arrowdown3 arrowdown4 arrowdown5 arrowdown5_solid arrowdown7 arrowdown6 arrow_left arrow_right filter download upload2 download2 hard_drive pencil_solid pencil signature register account_circle_solid account_circle address_card paragraph checkbox_unchecked checkbox checkbox_solid dropdown caret_square_down radio_unchecked scrubber location_solid location toggle_on toggle_off shield_check shield_check_solid clock clock_solid email_solid mail_bulk code tag tag_solid price_tags search sitemap file file_text_solid file_text option option_solid more_horiz more_vert more_horiz_solid more_vert_solid calculator key key Filled Key Icon keyboard eye eye_solid eye_slash_solid page_break view_day attach_file printer header h1 repeat repeater save sliders code_commit star star_full star_half linear_scale pie_chart stats_bars sms highrise mailchimp feed align_right align_left button browser cloud_upload_solid shuffle swap pallet fingerprint ghost heart_solid heart history import export label_solid label lock_open lock alt_lock dollar_sign percent notification external_link pageview_solid pageview settings stamp support text white_label authorize activecampaign aweber campaignmonitor constant_contact getresponse googlesheets building hubspot icontact mailpoet paypal icon sendinblue sendy salesforce salesforcealt stripe stripealt twilio woocommerce wordpress credit_card credit_card_alt cc_amex cc_discover cc_mastercard cc_visa cc_paypal icon cc_stripe price product total quantity directory Zapier Preview Additional information, questions, comments. Would you prefer to be contacted by telephone or email? Email Phone If you are human, leave this field blank. Submit