Are You Worried about Your Hair?

If you are worried about your hair and are concerned about
• Hair Loss • Thinning Hair • Dandruff • Dry Itchy Flaky Scalp, then,
please enter your details below and one of our Consultants
will contact you as requested, for an initial complimentary chat.

We will then advise, you as to the best way to proceed to help you improve your condition.

Your Hair or Scalp Concerns
Please complete all sections.*

Is your concern a? *
Hair Loss/Thinning Hair Problem Dandruff/Itchy Flaky Scalp Problem Both

Is your condition? *
Severe Moderate Mild


Your Details
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Your Name*

Best Contact Number*

Your Email*

Age* Male* Female*
Occupation*

How did you hear about Hairology?*
(Please Specify)

Was it on a?* Computer Mobile Tablet

When would you like us to call you.*
As soon as possible anytime 9.30am to 11.30am 12pm to 2pm 4.30pm to 7.30pm

Please give a brief description of your concerns and any previous treatment/advice below:*

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*At Hairology we are committed to protecting your privacy.
The information we collect about you is to provide with a more personalised service and tailored Advice, which is based solely on the information you provide. Hairology cannot be held responsible for any false or inaccurate information provided by you. By ticking this box and the submit button, you authorise and consent to the collection and use of this information by Hairology. All information is treated in the strictest confidence and for the use of Hairology only, your details are not shared with any third party. We respect your privacy. By clicking submit, you hereby state that you have read, undertsood and accept these Terms and Conditions and all information provided by you is true to the best of your knowledge.
* Please tick this box to confirm that you have read, undertsood and accept these Terms and Conditions.

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