Radiance Advanced Hair Treatment Center Rajahmundry

1) What is your gender? *

2) How old are you? *

3) How long have you been experiencing hair loss? *

4) Do the back and sides of your scalp have full, healthy hair? *

5) Do you have family members with similar patterns of hair loss? *

6) Do you currently use a hair system? (wigs, toupees, weaves, braids, etc)

7) Are you currently using any special medications, or have you recently been under a lot of stress?

8) On a scale of 1-5, how comfortable do you feel getting hair restoration surgery? (1 being "Not comfortable, 5 being "Very comfortable") *

Name *

Email *

Phone Number *

City *

We are located in Rajahmundry :