Appointment Request Form

EXPERIENCING HAIR LOSS CAN BE VERY EMBARRASSING AND FRUSTRATING

There are many women and men who struggle with losing their hair. According to the American Hair Loss Council there are approximately 40% of women that are experiencing some type of hair loss and there are over 50% of men who are experiencing hair loss.

Everyday women and men are looking for solutions for their hair loss disorders. At Follicles Hair Restoration Center we meet with many individuals to create a Holistic Comprehensive Non-Surgical Hair Loss And Hair Replacement services to assist with regrowing the clients Hair as well as restoring their scalp disorders.

Follicles Hair Restoration Center focuses on helping clients that are experiencing Female / Male Pattern Hair Loss,(AKA Androgenetic Alopecia) Hair Thinning, TELOGEN Effluvium, Traction Alopecia and Seborrheic Dermatitis.

Before starting any Non-Surgical Hair Loss and Hair Replacement services, Clients must receive a Scalp Exam.

NOW we are accepting ONLY 10 clients, that will receive a COMPLIMENTARY SCALP EXAM, which is a ($197 VALUE).

Are You Ready To Regrow Your Hair Thicker and Fuller? If Yes, Complete The Form Now! ONLY The First 10 Qualified Applicants Will Receive An Appointment, So DON’T DELAY, Get Your Appointment Scheduled TODAY!

Full Name*

First NameLast Name

Current Phone Number*

Area CodePhone Number

Current E-mail*

Health Issues*

Scalp Issues*

Hair Issues*

Available Day For a Call to Schedule You*

Date

Available Time For a Call to Schedule You*

:HourMinutesAM/PM Option