Hair Technologies: Providing professional quality hair loss prevention and replacement services.

Contact Us

Please fill out the form below completely so we can better understand your needs. You can also use our on-line form to schedule an appointment with us.

We can be contact via mail or phone at the following address and phone number:

Hair Technologies™
111 Elm St. Suite 104
Worcester, MA 01609
Phone: 508-753-9229 or toll free at 877-753-9229


First Name

Last Name

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Work Phone

Home Phone

E-mail

Date of Birth

Where has the hairloss occurred?
(A.)        ( B.)       (C.)       (D.)         ( E.)

How long have you been losing your hair?
1-3 years 3-7 years 7-15 years More than 15 Years

Is the scalp visible in the area where you have lost your hair?
Yes No

Do you suffer from...? (choose as many as applicable)
Dandruff Itchy Scalp Dry Scalp Oily Scalp

Would you characterize your existing hair as... (choose one)
Dry Oily Normal

Does your scalp ever flake?
Yes No

Do you ever see red blotches on your scalp?
Yes No

How would you rate your current rate of hair loss?
Light Moderate Heavy

Have you experienced an increase in your rate of hairloss in the past year?
Yes No

Have you ever tried to do anything about your hairloss?
Rogaine
Hair Transplant
Hair Replacement
Lotions/Shampoos
Nothing

Have you ever seen a doctor about your hair loss?
Yes No

Has anyone ever mentioned your hairloss to you?
Wife
Girl Friend
Husband
Boy Friend
Father
Mother
Other

If yes, Does that bother you?
Yes No

Why do you want to do anything about your hair?
(choose as many as applicable)
I look older than I feel.
I hate the way my hair looks
I want to meet younger men/women
people make fun of me

Do you want to:
Stop Hair Loss Have More Hair

Other Notes

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