virtual consultation

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

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

STEP 1: IDENTIFICATION * (denotes required information)
First Name *
Last Name *
Date of birth (yyyy-mm-dd)
City *
Province *
Postal code
Home phone
Cell phone
Best day / time to be reached
E-mail *
Do you have an active lifestyle?
If yes, what type of sports do you practice?
What are your expectations from Sage Hair?
When did your hair start thinning?
How would you describe your current hair loss?
Does baldness/thinning hair run in your family?
Have you seen a physician regarding your hair loss?
If yes, what was his/her recommendation?
What product(s) do you
use on your hair?


Which one?


Other product(s)

Are you on a hair treatment program?
If yes, which one and what are the results?
Do you suffer from:
If other, please specify:
Would you characterize your existing hair as:
The hair you are loosing is:
Does your scalp excrete excessive sebum (oil)?
Are you presently experiencing:

(hold “ctrl” to select more than one)

If yes, please describe:
On a scale from 1 to 10, how would you rate the emergency to treat you hair loss?
Less Urgent – 1 2 3 4 5 6 7 8 9 10 – More Urgent
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?

On the chart below, what image best represents the current status of your hair loss?



ludwig traction

ludwig totalis

ludwig areata

I understand that the information I provide will be kept in complete confidentiality and will not be distributed, sold or used for any other purposes than for us to communicate with you.
Sage  Hair Solutions, Calgary