First Name *

Middle Name

Last Name *

Phone No.(Home)

Phone No.(Business)

Phone No.(Mobile) *

+1 (US) +91 (India) +44 (UK) +61 (Australia)

Email *

Date of Birth

Occupation (Please Specify) :

Preferred Language

Select Language English Hindi

Name

Procedure Done

Select Procedure Advanced Laser Therapy Advanced Hair Check Solution Strand-by-Strand the Ultimate ® Strand-by-Strand Cosmetic® AHS Supernatural AHS Flashpoints Advanced Hair Studio’s Home Program Advanced Hair and Scalp Fitness Program (AHS-FP) AHS Complete Male Pattern Baldness Female Hair Transplant Cosmetic Hair Patch

Have you consulted any doctors / clinics? *

If Yes, please specify

In hair replacement, which other organisations do you know?

Was the treatment effective (if any)?

Before making the decision to visit Advanced Hair Studio:

1. How long did you take *

   1 Week

   1 Month

   3 Month

   3More than 3 months

2. Did you consult any other person or took the decision by yourself? *

   Please select at least one option.

   Myself

   Wife / Husband

   Parents

   Friends

   Hairdresser

   Other

What are your expectations from the treatment:

Where did you hear about Advanced Hair Studio?

On a scale of 1-5, how concerned are you that losing your hair will impact :

Would you be excited if a professional company ensures your hair style is always matching the world's latest trends according to your age group, profession and expectations?