Complete this form and we'll send you a certificate for 300 FREE GRAFTS (a $990 value) added to your hair restoration!

To take advantage of this special offer please take a moment to fill out this online consultation. We'll send you a certificate for 300 FREE GRAFTS added to your hair restoration procedure with AMERICAN HAIR TRANSPLANT CENTERS.

THIS OFFER IS VALID ONLY FOR SESSIONS SCHEDULED BEFORE JUNE 2011, FOR SINGLE SESSIONS RANGING FROM 1000-4000 GRAFTS. THIS OFFER MAY NOT BE COMBINED WITH OTHER SPECIAL INCENTIVES.

 

Full Name

Email Address

Comments

Mailing Address

Phone Number

Date of Birth

How long have you been experiencing hair loss?

In which areas has hair loss occurred?
Frontal Hairline Only   Crown Only   Front and Crown   

The hair around the back and sides of your head is:
Thick and Full   Thin and Sparse   Average   

Rate your current hair loss over the past year:
Excessive   Moderate   Slowing Down   

Have you tried other solutions to hair loss?
Yes   No   

 
I understand that this information is private and is only to be used internally at AHTC

I'd like more information about hair restoration at American Hair Transplant Centers...
by email   by phone   by mail   at a free consultation