Which best represents your hair loss goals? *

Slow progress of receding hairline

Experiencing hair loss, want to explore options

Experiencing hair loss, want to try something immediately

No hair loss yet, but want to get started

None of the above

Where are you noticing changes to your hair? *

Along the hairline

At the top

All over

How much hair have you lost? *

A lot

Some

A little

When did you start noticing changes to your hair? *

Over a year ago

In the past year

In the past few months

Not sure

What is your treatment goal? *

A stronger, better defined hairline

Visibly thicker, fuller hair

More scalp coverage

Keep the hair I have

All of the above

What’s your hair type? *

Straight or wavy

Curly or coily

Textured or processed

I don't know

How long is your hair? *

Buzzed, shaved, or bald

Short

Medium

Long

Does hair loss run in your family? *

Yes

No

Unsure

How often do you tend to experience stress? *

Nearly everyday

Multiple times a week

A few times a week

A few times a month

Rarely

How do you style your hair? *

No styling

Products

Usually with a hat

Protective styles like braids

How much time do you spend on your hair every day? *

Less than 5 minutes

5-10 minutes

More than 10 minutes

Which type of daily treatment do you prefer? *

Pills or chews

Sprays or serums

No preference

Please upload as many clear photos of your scalp as you can.

Click to upload

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF If possible, please upload the photos directly from your mobile device.

Congratulations on starting your hair loss treatment at Prestige 2.0.

Someone from Prestige 2.0 will reach out to you shortly to complete the medical evaluation. Please provide the following information and then schedule your appointment.

First Name *

Last Name

Phone *

Email *

Date of birth *

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