‘Take 2 Minutes To Complete This Form To Apply To Work With Dr. Perlman & Save Your Hair’

What stage of hair loss are you in?

Early Hair Thinning or Minimal Hair Loss

Receding Hairline

Moderate Hair Loss or Widening Part

Advanced Hair Loss

Severe or Full-Scale Baldness

How long have you been experiencing noticeable hair loss?

Less than 6 months

6 months to 2 years

More than 2 years

What other treatments have you already tried for your hair loss? (Select all that apply)

Over-the-counter remedies (e.g., minoxidil)

Prescription medications

Derma-rolling

Natural remedies

Laser therapy

None

What is most important to you for your hair restoration treatment plan? (Select all that apply)

Stop the hair loss ASAP

Improve my confidence and self-image for dating, work, etc.

Grow new hair and fix my hairline

Understand more about hair loss treatments

Make sure my hairline looks natural

Acting quickly is key to managing hair loss. Are you ready to take the next step to reach your goal?

Yes

Is there anything else you think Dr. Perlman should know about your hair loss journey?

Consultation Requirements: *

I understand that this is a $250 paid consultation with Dr. Perlman, and that if I choose to go ahead with the treatment plan with TIFAAR, my consultation fee will be fully deducted from my treatment plan.

Final Step!

Enter Your Information Below to See If You Qualify.

First Name *

Last Name *

Phone *

Email *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.