FREE DVD and Natural Hair ransplantaion Educational Guide

Sign-up for PAI ConsultLive™

Now you can conduct a FREE hair consultation from the comfort of your own home with a PAI Hair Restoration Consultant.

Getting started is easy! Simply fill in our secure online questionnaire and a PAI Hair Restoration Consultant will contact you within two business days.

Please note that all fields with an * are required.

Contact Information

First Name:*

Last Name:*

Address 1: *

Address 2:

City:*

State/Province:*

If other:

Zip/Postal Code:*

Country:*

Telephone:*

xxx-xxx-xxxx

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contacted by:*

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Please select
your time zone:*

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Time 1:*	HR:MIN	AM PM
Time 2:*	HR:MIN	AM PM
Time 3:*	HR:MIN	AM PM

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Hair Loss Evaluation

Age:*

Gender:*

Male Female

Select the image that best describes your hairloss condition when your
hair is wet.*

Norwood (male)



Ludwig (female)

Please rank the concerns that apply to your feelings about hair restoration
surgery in order of importance to you (1 = your greatest concern).*

	Camouflaging after surgery
	Affordability
	Discomfort
	Final result
	Time off work
	Other

At what age did you first notice your hairloss?

< 20

21-30

31-40

41-50

50+

Please indicate in which areas your hair loss affects you:

	When I see pictures or videos		My self-esteem
	At the beach or swimming		In my social life
	When I get dressed up		When I see old friends
	When I have to wear a hat		It doesn't bother me

What would you like to achieve with hair transplantation (restore the front
hairline, mid scalp, back, or your entire balding area)?*

Have you consulted with a doctor about your hairloss condition?

Yes

If so, with whom?

Have you ever had surgical hair restoration performed?

Yes

How were you
referred to PAI
Medical Group?*

If Other:

Preferred Clinic*

Yes, I would like to receive the HairZone newsletter

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Toll-free: 1-877-PAI-HAIR

PAI Hair Transplant clinics are located throughout the United States and Canada and offer a full range of hair restoration services including Hair Transplantation with our exclusive Multi-Unit Hair Grafting™, Hair Loss Prevention Treatments or Low Level Laser Treatments for hair loss. PAI Hair Transplant Clinics specialize in natural solutions for all types of male and female hair loss problems.
PAI wants you to be completely satisfied with your experience and values the trust and confidence you have placed in us. We look forward to hearing from you to discuss any questions you may have regarding solutions for your hair loss.

More Information

	Click here for a listing of our hair transplant clinics
	Click here to conduct a free PAI ConsultLive Hair Transplant and Hair Restoration Consultation over the phone and Internet.
	Click here to download our PAI Educational Guide discussing baldness cures, hair loss cures, various hair loss treatments and how our hair transplant and hair restoration process works.