Green Bay
904 S. Military Ave.
Green Bay, WI 54304
920-499-3300
800-292-1037 		Neenah
562 S. Green Bay Rd
Neenah, WI 54956
920-725-0662
800-236-0002
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Please complete our Virtual Consultation form below.  When complete, click on 'Submit'  and a representative from Keith's Haircenter will contact you in the manner requested.

 
Last Name
First Name
Street Address
City
State
Zip Code
Home Phone
Email Address
How would you like to be contacted?
Occupation
Age Range
Marital Status
Birthdate (mm-dd-yyyy)
How did you hear about Keith's Haircenter?
How long ago did you receive our information kit/brochure?
How old were you when you first noticed your hair loss?
Does baldness run in your family?
Are you aware of any scalp disorders you may have?
Please list any medications you are taking.
What attracted you to Keith's Haircenter?
What concerns do you have about restoring your hair?
What activities do you participate in? Please check all that apply.




Please list other activities you participate in.
Please indicate in which areas your hair loss affects you. Please check all that apply.











From the images below, please choose the image that most closely resembles your hair loss.
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