Tell us about your hair loss or scalp problem. Our Beijing-trained Hair Consultants will call you back with the solution, free of charge. Act now to save your hair.
STRICTLY PRIVATE AND CONFIDENTIAL
(A)Personal Particulars
*Name:
Do you reside in Singapore?
Yes
No
Gender:
Male
Female
*Email:
*Contact No. (1)
Mobile
Office Tel
Home Tel
Contact No. (2)
Mobile
Office Tel
Home Tel
*These are required fields.
(B) Problem
1) My hair concern is
Hair Loss
Thinning Hair
Dandruff
Dry Scalp
Oily Scalp
Itchy Scalp
Grey Hair
Dry Hair
2) How many strands of hair do you lose a day?
1-100
100-150
150-200
More than 200
Not Sure
3) How long have you been suffering from this condition?
0
1
2
3
4
5
6
7
8
9
10
11
12
Month
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Year
(C) Medical History
1) Are you suffering from illness?
Yes
No
Name of illness:
2) Are any of your family members suffering from baldness/thinning hair?
Yes
No
3) Have you been treated by any doctor or hair care centre for your hair/scalp problems?
Yes
No
(D) Lifestyle
1) Your occupation:
Working Indoor
Working Outdoor
Student
Housewife
Retired
2) Your life is :
Very stressful
Stressful
Manageable
Relaxed
