Hair Extension & Hair Replacement Evaluation Survey Questionnaire (KiaStyles + Allthatandmorehair.com) 678-663-5298

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Answer the following questions to find out if you are a good candidate for hair extensions and or hair replacement. Upon completion of this form, Kia will review your situation, if you indicate that you would like a free private salon or phone consultation, Kia will call you to discuss different options.

Are you experiencing hair loss? If yes, when did you first notice your hair loss?

What type of hair loss do you have?

Thinning hair loss

Alopecia

Chemotherapy/Radiation

Other

None

Are you being treated by a medical doctor for hair loss or thinning?

What remedies have you tried ?

Rogaine

Propecia

Other

Not Applicable

Do you avoid social situations due to hair loss?

Yes

Sometimes

Clear selection

What were the results of past hair loss remedies?

Are you allergic to anything?

My main purpose for seeking information about hair extensions is that

I want fuller and/or longer hair

I am interested in a specific style

I want to coverup thinning hair

Other:

I am interested in a free no obligation phone consultation to discuss hair solutions and options.

Phone Number:

Name:

State:

ZIP:

Email tips, videos and discounts. 100% FREE! + Wear Smart Tips, tricks, videos and insider info for your hair-care maintenance + do-it-yourselfer:)

Email Address:

Would you like Shop Smart Instant coupons, savings and discount promotions for the savvy shopper + in-store events.

Yes

Clear selection

SMS Text Message Signup. Enter your mobile carrier to have special offers sent to your mobile device.

My Mobile Carrier Is:

Submit

Clear form

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