Thank-you for choosing to take the next step in solving your hair loss. Remember by filling out the consultation form on this page and or booking an appointment you get $300.00 off the fee of Surgical or Non-surgical Hair Restoration.

The information you share with us is kept within a secured file on our server and no-one other than your assigned hair loss specialists has access to the information.

First Name:  
Last Name:  
Age:  
Address:  
City:  
Province/State:  
Country:  
Postal Code/Zip Code:  
Day Time Phone:   - -
Evening Phone:   - -
E-mail:  

How can Sir 101 contact you?
Telephone By Mail Email

* Please fill out the information below if you would like to make an online appointment.
Choose from the following.
Book an Appointment Have Sir 101 phone you for a Consultation

If you checked make an appointment, please fill out what day and time you would like to book.
 
Day:   9:00am - 5:00pm  

Appointment Comments:

What is the number one reason you want more hair?:

Your hair loss bothers you most when?
Please number 1-5, 1 being most important.
During Work Socially During a Date Family Gatherings Other
If Other: please explain

How long has your hair loss been occurring?		 years   months

Have you seen any surgeons, doctors or other hair replacement clinics?		 Yes   No

If Yes: who did you visit?

If yes to the above:
What was the cost?
What was the required work?

Have you ever looked at any other hair restoration techniques before?		 Yes   No

If Yes: what did you look at?
Hair Replacement Non-surgical Graft Hair Transplants
Hair Growth Formulas Propecia Rogaine

Sports you take part in:

What do you think Hair Restoration should cost for your hair loss?

If we can provide what you are looking for, are you prepared to do something right away?		 Yes   No

If No: What would prevent you from doing something about your hair loss?
Please number 1-4, 1 being most important.
Cost Amount of Hair How natural the result is Other
If Other: please explain

Which Norwood hair loss pattern matches your hair loss the closest?
Click here to view the Norwood chart

How did you find out about Sir 101?
Newspaper Television Direct Mail Internet

Marital Status
Married Single Divorced Children - yes no