Join our Referral Membership Program

Join our Team by filling out the form below.

When you send a patient our way, you will receive direct benefits as a result of every patient who completes the hair restoration procedure at Robotic Hair Rx. We will contact you with marketing material to get started!

How do we know you sent the referral patient?

Write your name in the “Referred By” section of your marketing material before handing it out, tell them to mention your name at their consultation, or just fill your name in when they submit a contact form online!

Name*
Occupation*
Name of Company
Address
Street Address City State / Province / Region ZIP / Postal Code
Email*
Phone Number
Sent By*
Name
This field is for validation purposes and should be left unchanged.

Find Us

1215 W. Rio Salado Parkway Suite 105, Tempe, AZ 85281

Call Us
(480) 597-3488