The condition of your hair is a concern?
We understand. And this virtual consultation will bring you one step closer to finding the hair solution that will work best for you.

By filling out this questionnaire, you will help us learn a little more about your particular hairloss situation. We will then be able to establish a preliminary diagnosis, and suggest appropriate hair alternatives.

Rest assured that this virtual consultation is a matter we treat with the utmost privacy and we will never disclose your information to any third parties. Also keep in mind that this form and any reply to it cannot take the place of an actual in-person consultation.

Capilia respects your privacy.

"I understand that the information I provide with this Virtual Consultation will be kept in complete confidentiality and will not be distributed, sold or used for any purposes other than for Capilia to communicate with me".

Part 1: Your contact information:
Capilia *requires contact information to respond

Additional Information:

Date of Birth: (yyyy-mm-dd)


Occupation:


Best time to contact:
Weekday Weekend Monday Tuesday Wednesday Thursday Friday Saturday Sunday Daytime Evening

* First Name:

* Last Name:

Address:

* City:

* Province:

Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territories

Postal code:

Home phone:

Cell phone:

* Email:

Part 2: About your situation:

Do you have an active lifestyle?

Yes No

If yes, what type of sports do you practice?

What are your expectations from Capilia?

Stop your hair loss Have more hair Treat a specific problem Other

When did your hair start thinning?

How would you describe your current hair loss?

10-20 hairs a day 21-40 hairs a day 41-99 hairs a day More than 100 hairs a day

Does baldness/thinning hair run in  your family?

Yes No

Have you seen a physician regarding your hair loss?

Yes No

If yes, what was the recommendation?

What product(s) do you use on your hair?

Shampoo  times/week    
Which one?

Coloration   times/month
Other product(s) 

Are you on a hair treatment program?

Yes No

If yes, which one and what are the results?

You suffer from ...

Dandruff Itchy scalp Dry scalp Oily scalp Other

If other, please specify:

You characterize your existing hair as ...

Dry Oily Normal

The hair you are loosing is ...

Coming out with the root It is breaking

Does your scalp excrete excessive sebum (oil)?

Yes No

Are you presently experiencing:
(hold "ctrl" to select more than one)

- please select - Professional Stress Medical Treatment Personal Stress Sickness Severe Diet Menopause Medication Pregnancy

If yes, please describe:

On a scale from 1 to 10, rate the urgency to treat your hair loss (10 being most urgent)

1 2 3 4 5 6 7 8 9 10

Who supports your decision to treat your hair loss?

How would you like your new "look" to be?

Do you presently have or have you ever had any type of surgical or non-surgical hair replacement?

Yes No

What image best represents the current status of your hair loss?