Global Trichology Network

Please fill out the appointment request and intake form below. Answer each question to the best of your knowledge and also let us know what your primary hair and/or scalp questions or concerns are. As soon as we receive your appointment request you will be contacted to confirm your appointment. 

Service Request*
High Blood Pressure*
Diabetes*
Thyroid Condition*
Heart Disease*
Allergies *
Vitamin Definciencies*
Hair Information: Check all that apply
Color
Hair Strands
Scalp
Scalp
hair shedding
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Thank you for contacting us. We will get back to you as soon as possible to confirm your appointment or answer any questions you may have.