Birth Control Assessment | Guci Image Inc

Birth Control

Hair Loss Assessment

9 Out of 10 People

Who Take This HAIR LOSS ASSESSMENT

Find The Solution To Their Hair Loss!

1. How long have you been on birth control?*
- Less than 1 year
- 2-5 years
- 5-10 years
- More than 10 years
2. Have you taken or used in the past 5 yrs. any of the birth control listed below?*
- Yaz or Yazmine
- Mirena or any other IUD
- Ortho Tri-Cyclen or Lo Loestrin
- Other
3. How many times have you switched the brand of your birth control in the past 5 years?*
- None
- 1 time
- 2 times
- 3 or more times
4. How many times have you gone ON and OFF birth control in the past 5 years?*
- None
- 1 time
- 2 times
- 3 or more
5. How old are you?*
- Less than 21
- 21 to 45
- 45 to 55
- 55+
6. How long have you been losing hair or thinning?*
- Less than 1 year
- 2 to 5 years
- 5 to 10 years
- 10+ years
7. Does anyone else in your family suffer from hair loss or thinning hair?*
- Yes
- No
8. Do you take any other medication that require a doctor's prescription other than birth control?*
- Yes
- No
9. Have you had any weight loss or weight gains of 10 pounds or more in the past 12 months?*
- Yes
- No
10. Have you suffered any life altering events that can be classified as “traumatic” in the past 5 years?*
- Yes
- No
First name*
Last Name*
Email*
Phone*
Please describe your hair loss issue*
Before we begin your Hair Loss Assessment, please check the box below acknowledging that in order to protect your Privacy the results of your assessment WILL NOT be shared through Email or Text.*
- YES, I wish to receive a call from the Hair Loss Specialist to discuss my results.
Best Time To Call 📞*
- Morning
- Afternoon
- Eveninig
*Disclaimer: This is a general and preliminary assessment. An In-person Consultation and Scalp examination is necessary for a full treatment recommendation.
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About
30 Sec Hair Loss Assessment
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- Stress
- Thyroid
- Menopause
- Weight Loss
- Birth Control
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