Please complete the client evaluation form and submit to Images Unlimited to allow us to evaluate and help determine a customize hair loss program that best suits your individual need. Based on your information, our hair loss professionals will respond with a recommended treatment or contact you for a personal consultation. Remember, your information is always confidential.

To contact Images Unlimited by email - information@imagesunlimited.org


Hair Loss Treatment Evaluation

First Name:  Last Name:
Email:   Phone: (Optional)
How long have you noticed hair loss?  Years    or Months    Other
Has your hair loss been sudden or gradual?
Please explain:
Is your hair loss getting worst?   Yes   No
How many hairs lost per day?
Does hair loss run in your family? Yes   No
If yes, what side(s) of the family? Father   Mother Both
Rate your stress levels  High Medium Low
What options have you researched for your hair loss?
(Include over the counter and prescriptions)

     Transplants      Scalp treatments      Hair Replacement or weaves
     Over the counter products      Prescription products      Avacor
     Minoxidil percentage      Other      Clubs or Clinics
How much does your hair bother you?  Slightly   Moderately   Highly
How has your hair loss affected you? Socially   Professional   Personally
Would you consider using prescription strength topicals and pills if you could get better results? Keep in mind, prescription products in general increase cost?
Yes No

What are your goals and expectations with a potential treatment?

Prevent further loss Gain back hair quickly Gradually gain back some hair

Other:

 
This is a Hair Wellness Program that Creates a Foundation for Hair Restoration.

To set up your consultation today, please fill in our questionnaire - click here
Consultations for Hair Loss - Virginia Beach
Consultations for Hair Loss Treatments - Virginia Beach

We offer consultations for:

Hair Loss/ Thinning Hair
Broken/Damaged Hair
Scalp Conditions
Chemotherapy
Alopecia Areata
Traction Alopecia
Hair Loss Treatment Products

Hair Loss Treatments - Virginia Beach


Unmatched Hair Loss Treatment Programs

Innovative Solutions, Exceptional Results

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