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Dermatex International
5703 Oberlin Drive
Suite 302
San Diego, CA 92121
To receive additional information on Virtual Reality and other Dermatex International services, please send us an email with your request and how we can contact you, or call us directly.

(866) 589-9957
 
 
 

 
     

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Everybody is different so Please tell us a little about yourself so that we may better assist you with the correct information and options.
 
 
 
  A field with an (*) indicates a required field. I have a hair loss problem.
How can we help you?
Gender(*)
Male Female
MALE
hair treatment virtual consultant
hair treatment virtual consultant

hair treatment virtual consultant
Which best describes your hair loss?:

 
 
Grade I
Grade II

Grade III

FEMALE
FEMALE - choose one
FEMALE - choose one

FEMALE - choose one
Which best describes your hair loss?:

 
Grade I
Grade II

Grade III

Which hair loss do you most likely have:
Characterize the hair on sides of your head?:
How long have you been losing hair?: 1-3 years 3-7 years 7-15 years Over 15 years
Characterize rate of your current hair loss?: Light Moderate Heavy
Which of the following have you tried or are you currently using?:

 (Check all that apply)

Hair Transplant

Hair Replacement

Wigs / Hair Extension

Medication/Rogaine/Propecia

Vitamins; special shampoos; etc

Laser

None of the above
What is your age range?(*):
    
First Name(*):  
Last Name(*):  
Street:
City(*):  
State(*):  
Zip(*):  
Country(*):
Email(*):  
Daytime Phone(*):
Evening Phone:
Best way to reach me:
How did you learn about us?
Inquiry:
 
 
     


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