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Contact Our Office for a FREE Consultation
To schedule your personal and private consultation with a CJ's Hair Technologies hair replacement professional, just complete the form below. We will help you identify the best approach to your particular type of hair loss and answer all your questions in straight-forward, easy to understand terms. This confidential appointment is completely complimentary and without any obligation. Coming in from out of town? If you are ready to schedule your trip, please call us at 1-812-882-3800.

YOUR PRIVACY: We respect the privacy of our clients. CJ's Hair Technologies will not sell or share any information gathered online or otherwise to any third party. Your visits to our offices, and all information collected is kept strictly confidential.

* First Name

              

* Last Name

              

Address

City

State / Province

Zip Code

* Best Contact Phone

 include area code

Best Time to Call

 HH:MM am/pm

* Email

Source of Referral?

Gender
 Male    Female
Men: Please select the image that best matches your current hair loss pattern.
Ladies: Please select the image that best matches your current hair loss pattern.
At what age did you begin to notice hair loss?
20 or younger
21-30
31-40
41-50
51-60
61 or older
How would you rate your current rate of hair loss?
Light
Moderate Heavy
Have you ever tried to do anything about your hair loss?
Rogaine
Propecia
Hair Transplant
Hair Replacement
Lotions/Shampoos
Suppliments
Do you have
any questions
or comments?
Would you like travel package info?
 Yes    No
Date Desired for Consultation?
 MM:DD:YY

Verification Code

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