Looking great is what we do - Hair loss solutions
Micro follicular hair transplant

Virtual consultation

You do have options!

Regency Hair provides a number of hair loss treatment and prevention options, both surgical and non-surgical. This virtual consultation will bring you one step closer to finding the hair solution that will work best for you.

To request a consultation please complete the form below. Or call us during office hours at (613) 241-6111. We're looking forward to hearing from you.

 Please fill in all fields marked with an asterisk (*).

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IDENTIFICATION

First name: * Last name: *
Age: Sex: * Male Female
Address: City:
Province: Postal Code:
Primary phone: ex.999 999-9999 Other phone: ex.999 999-9999
Email: * Confirm Email: *
Best time to be reached
QUESTIONNAIRE
Do you have an active lifestyle? No
Yes    If yes, what type of sports do you practice?
What are your expectations from Capilia?
When did your hair start thinning?
How would you describe your current hair loss?
Does baldness/thinning hair run in  your family? No Yes
Have you seen a physician regarding your hair loss? No
Yes    What was his recommendation?
What product(s) do you use on your hair?  
Shampoo :   times/week      Which one?
Coloration:   times/month  
Other product(s) :
Are you presently on a hair treatment program? No
Yes    Which one and what are the results?
Do you suffer from…? Dandruff Dry scalp
Itchy scalp Oily scalp Other, please specify:
Would you characterize your existing hair as…?: Dry      Oily      Normal
The hair you are losing is: Coming out with the root      It is breaking
Does your scalp excrete excessive sebum (oil)? No      Yes
Are you presently experiencing?: Menopause Medical Treatment Personal Stress
Sickness Severe Diet Professional Stress
Pregnancy Medication  
If so, please describe:
On a scale from 1 to 10, how would you rate the emergency to treat you hair loss? (10 being the most urgent)
1 5 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?       No     Yes
On the chart below, what image best represents the current status of your hair loss?
NorwoodAA NorwoodBB NorwoodCC NorwoodDD
NorwoodEE NorwoodFF NorwoodGG NorwoodHH
NorwoodII NorwoodJJ NorwoodKK NorwoodLL
Additional informations or comments:
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Hair restoration

325 Dalhousie St. Suite 464, Ottawa, ON K1N 7G2

Tel.: (613) 241-6111 Fax.: (613) 241-4492