Bilowus Medical

To schedule your free consultation and receive more information about Bilowus Medical's safe and effective hair restoration, please complete the form below. To speak with a representative, call toll-free at (866) 895-2261. At your consultation, you will also receive a $100 Savings Certificate for hair transplant surgery.

What type of hair loss information would you like to receive? *
Surgical Non-Surgical Both

First Name:		*
Last Name:		*
Address 1:		*
Address 2:
City:		*
State:		*
Zip:		*
E-mail:		*
Phone:		*
Year of Birth:		*

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

2. Where has the hair loss occurred?
(A) (B) (C) (D) (E)

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

4. How would you characterize your hair type?
Dry Oily Normal

5. Is hair growing on the sides of your head?
Thin and full Thick and full Thin and slightly receding

6. Does your scalp ever flake?
Yes No

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

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

9. Have you ever experienced an increase in your rate of hair loss in the past year?
Yes No

10. Have you ever tried to do anything about your hair loss? (select all that apply)
Rogaine Hair Transplant Hair Replacement Lotions/Shampoos Nothing

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

12. Have you had prior hair replacement surgery?
Yes No

13. Has anyone ever mentioned your hair loss to you? (select all that apply)
Wife Girlfriend Husband Boyfriend Mother Father Other

14. Does that concern you?
Yes No

15. Why do you want to do something about your hair? (select all that apply)
I look older than I feel I hate the way my hair looks I want to meet younger women/men People ridicule me

16. Do you want to:
Stop your hair loss Have more hair

17. Are you willing to travel to the Washington Metro area for a consultation?
Yes No