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Am I a Candidate?
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Fill out our Virtual Questionnaire to see if you are a Candidate!
First Name
*
Last Name
*
Email Address
*
Phone Number
*
How old are you?
*
Please enter a number from
0
to
100
.
How long ago did you start experiencing hair loss?
*
What concerns first drew your attention to your hair loss? (Multiple Choice)
*
Negative comments
I noticed hair falling out
I saw photos of myself
Looking older
Feeling insecure
Feeling less attractive
Other/Unknown
Please describe
Select your current hair status:
*
Select your father’s hair status:
*
What would be the best thing about having your hair back? (Multiple Choice)
*
I’d look younger
I'd feel more secure
I’d be more attractive
Other/Unknown
Please describe
Have you tried other options? (Multiple Choice)
*
Rogaine
Wigs
Propecia
Hair Transplantation
Other
No
Please describe
Do you have any concerns about hair restoration? (Multiple Choice)
*
Pain
Cost
Scarring
Other/Unknown
None
Please describe
Are you interested in other non-surgical hair restoration options?
*
Yes
No
Would you like to learn more about the ARTAS iX FUE Procedure?
*
Yes
No
Please submit your images for review!
Images
Please include FACE view of your hair:
*
Accepted file types: jpg, png, pdf, Max. file size: 2 MB.
Please include HAIRLINE view of your hair:
*
Accepted file types: jpg, png, pdf, Max. file size: 2 MB.
Please include TOP OF THE HEAD view of your hair:
*
Accepted file types: jpg, png, pdf, Max. file size: 2 MB.
Please include DONOR AREA view of your head:
*
Accepted file types: jpg, png, pdf, Max. file size: 2 MB.
Please include LEFT PROFILE HAIRLINE view of your hair:
*
Accepted file types: jpg, png, pdf, Max. file size: 2 MB.
Please include RIGHT PROFILE HAIRLINE view of your hair:
*
Accepted file types: jpg, png, pdf, Max. file size: 2 MB.
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West LA Hair Restoration
West LA Hair
