Complete this form and we'll send you a certificate worth $1,000.00 towards your hair restoration!

Register here for our FREE HAIR LOSS Seminar on Saturday May 17th in our Raleigh office.

To take advantage of this special offer or to register for our free hair loss seminar on Saturday May 17th, please take a moment to fill out this online consultation. We'll add $1,000 worth of FREE GRAFTS to your hair restoration procedure with AMERICAN HAIR TRANSPLANT CENTERS.

THIS OFFER IS VALID ONLY FOR SESSIONS SCHEDULED IN MAY,JUNE & JULY 2008, FOR SINGLE SESSIONS RANGING FROM 1000-4000 GRAFTS. THIS OFFER MAY NOT BE COMBINED WITH OTHER SPECIAL INCENTIVES.

 

Full Name

Email Address

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