virtual
consultation
LANGUAGE/LANGUE:
ENGLISH
FRANÇAIS
FIRST NAME *:
LAST NAME *:
DATE OF BIRTH:
e-mail adress*:
ADRESS:
city:
PROVINCe / state:
POstal code / zip code:
PHONE #1:
PHONE #2:
BEST TIME TO CONTACT YOU:
OCCUPATION:
IT’S BETTER TO CONTACT YOU BY:
HOW WERE YOU REFERRED TO CLINIC MON CHEVEU?
a friend
yellow pages
internet
billboard
radio ad
magazine
newspapers
hospitals
television
by mail
other
WHAT ARE YOUR EXPECTATIONS?
stop my hair loss
have more hair
treat a specific problem
other
WHICH PATTERN MOST CLOSELY MATCHES YOUR HAIR LOSS SITUATIONS?

a

b

c

d

e

f

g

h

i

1

2

3

4

5

6

7

8

9

10

11
HAVE YOU TRIED TO DO ANYTHING ABOUT YOUR HAIR LOSS? (CHECK ALL THAT APPLY)
rogaine/propecia
transplant
laser therapy
Wigs
natural products
hair replacement
other
WHAT IS YOUR MOTIVATION TO SOLVE YOUR HAIR LOSS? (CHECK ALL THAT APPLY)
I look older that I am
I feel older that I am
I want to regain confidence
i want to regain self-esteem
i want to feel better at work
I want to please and seduce
DID YOU FEEL THAT YOUR HAIR LOSS PROHIBITS YOU FROM BEING “WHO YOU REALLY ARE”?
yes
no
ARE YOU READY TO DO SOMETHING ABOUT YOUR HAIR LOSS SITUATION NOW?
yes
no
i'm not sure
I'M only looking at my options
other
WHO SUPPORT YOUR DECISION?
friends
wife/husband
children
family
nobody
ON SCALE FROM 1 TO 10, RATE THE URGENCY TO TREAT YOUR HAIR LOST (10 BEING MOST URGENT)

PLEASE NOTE THAT WHEN VIEWING IN A PRIVATE CABIN, A PICTURE OF YOU WITH WHOM YOU FEEL AT YOUR BEST YOU WILL BE ASKED
*required