Take Control of Your Hair Loss Today, and Fill Out Our Hair Loss Quiz!

You’re about to take the first step in restoring your hair! By taking this quiz, you’re headed in the right direction to feeling your best and loving your hair. Get started by answering the following questions.

Once you submit your responses, a Custom Design Hair Representative will contact you as soon as possible.

1. How would you describe your current degree of hair loss?*
Please select your current degree of hair loss.

2. My hair loss is:*
Please select the severity of your hair loss.

3. How long have you been experiencing hair loss?*
Please enter the amount of time you have been experiencing hair loss.

4. Do any of your "blood relatives" have hair loss or thinning hair?*
Please answer if any of your "blood relatives" have hair loss or thinning hair.

5. Have you ever been diagnosed with a medical condition that could be related to your hair loss?*
Please answer if you ever been diagnosed with a medical condition that could be related to your hair loss.

6. How has hair loss affected your life?*
Please enter how hair loss has affected your life.

7. Have you tried or considered hair loss replacement options?*
Please enter if you have tried or considered hair loss replacement options.

8. I’m interested in learning about: (check all that apply)*
Please select what you are interested in learning about.

First Name
Please enter your first name.

Last Name
Please enter your last name.

Email
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Phone
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