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Virtual consultation form

One of our Norgil capillary experts will permit you, by this consultation, to see and approch your personal problem in all discretion. This consultation is free, and will direct you to what solutions apply to you.

* All the space marks with an asterisk must be filled.

First name : Name :
* *
Address : City :
Province : Postal Code :
Phone :
Home *
Work
Cellular
E-mail :
 *
Age : Sex :
Male :  Female : 
Specifical informations
Is your hairs falls abnormally ? Yes  No 
Since how long did you lose your hairs ?
Do you think that the fall of your hairs is genetic ? Yes  No 
Do you wash your hairs ?
Color of your hairs
Is your hairs are chemically treats? Yes  No 
If so, are they :
Aspect of your scalp
Texture of your hairs
Nature of your hairs
Length of your hairs
Itching Yes  No 
Are you allergic to fish ? Yes  No 
On a scale of 1 to 10, which importance do you grant to the reconstitution of your hairs ?
On the scale, which picture is the most representative of your hair capital ?
Hamilton scale








Ludwig scale



Additional informations, questions, comments :


  
  Direct access to our French friends