Online Consultation

1a. Age*

1b. Gender*
 Male Female

2. What color is your hair?

3. What color is your skin?

4. Which best describes your natural hair?

5. What is the texture of your hair?

6. What is your ethnic background?

7. Select which is closest to your hair loss condition when your hair is wet* Type 2Type 3Type 4Type 5Type 6Type 7

8. At what age did you begin to notice hair loss?

9. What are your hair restoration goals and what would you like to achieve (for example: restore the front hairline, mid scalp, back, or your entire balding area with CIT, Strip or BHT)?*

10. Have you consulted with a doctor about your hair loss condition?
 Yes No
If Yes, With Whom?

11. What treatment, if any, was recommended?

12. Have you ever had surgical hair restoration performed?
 Yes No
If Yes, With Whom?

13. Have you treated your hair loss with any of the following?
 Rogaine Propecia Saw Palmetto Avodart

14. Do you have any medical issues?*

15. What is your family hair loss history?

Please add any additional questions or comments

Your Contact Information
This form does not replace an actual in-person consultation. It is merely intended to provide us with an initial idea of your hair condition and hair restoration goals. With all of this information, we can provide you with an informed assessment and hair restoration plan.

First Name*

Last Name*

Email Address*

Street Address Line 1*

Street Address Line 2

City*

Country*

State/Province

Zip Code*

Phone

I prefer to be contacted by
 Phone Email

Preferred Procedure*

How did you hear about us?*

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