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ABHRS

Hair Transplant Network.com
IAHRS American Hair Loss Association

Information Request



True & Dorin customer service is awaiting your call. Please call our toll-free number at 1-866- HAIR MDS (424-7637) for any questions and inquiries.  At your request, we will send you, free of charge, our literature on hair loss.

Complete this form to submit it electronically for ONLINE CONSULTATION or print it out and fax it to us at (212) 980-5696 and we will call you back during working hours to answer your questions or schedule and IN OFFICE CONSULTATION

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First Name:*
Last Name:*
Job Title
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Address:*
City:*
State/Province:*
Zip Code:*
Country:
Phone USA/CANDA:  
Home:    - -
Work:    - -
Phone INTERNATIONAL:  
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Note: your response will be sent to this email address
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Yes, I would like a free brochure and

Video:
DVD:


How did you hear about us?

Current Age:
Age first noticed:
Are you still losing hair?
Has hair loss pattern stabilized, and for how long?
 
Do you use Propecia?  Yes  No
Do you use Rogaine?  Yes  No
Do you use any other hair loss products?
   Yes  No
Have you had prior procedures?
   Yes  No
If yes, are you satisfied with your results?
   Yes  No


For online consultation please attach pictures:

Provide these four views of you now:


Provide picture of you showing the hairline and look you would like to recover:








Print out form for faxing or mailing