Hairfax, a clinic network specialized in
hair transplant, non-surgical replacement and prevention of hair loss

Online Consultation Form

This Personal Consultation form is an opportunity for you to contact a Hairfax consultant. Simply fill out this form and send it to us to receive a free, interactive consultation.

For a better mobile experience, please flip your cellphone.

* All fields marked with an asterisk are requiered.

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

Specific information
How long has your hair been thinning?
Do you think your hair loss is genetic?	Yes No
What is the colour of your hair?
Type of hair:
Texture:
Nature of hair:
Length of hair:	cm
Itching of scalp:	Yes No
On a scale of 1 to 10, how would you rank the importance of restoring your hair?

On the chart below, what image best represents the current status of your hair loss?

Additional information, questions, comments...

Which of these services are you interested in ? *
Which Hairfax Center ? *
You want to be reach by phone or email? Email Phone

Online Consultation Form

Specific information