Seminar Location

Date *

First Name *

Last Name *

Home Address *

City *

State

Zip *

Home Phone *

Work Phone

Cell Phone

Email Address *

Date of Birth *

You may contact me at *

Age *

Sex *

Marital Status *

Have you visited our web site? *

Have you attended a IHTI Seminar? *

Have you had a previous consultation for hair restoration surgery by another medical group? *

Please select the ONE source that was most responsible for you coming here. *

What SPECIFIC source TV/radio station, newspaper/ magazine, internet site are you referring to above?

If you were referred by a physician, friend or another patient of IHTI whom may we thank for the referral?

What age did hair loss begin? *

Please type or circle the Norwood Scale that most reflects your current hair loss *

Please explain your goals and expectations for your hair transplant, inc. FIT, STRIP, areas, be specfic
*

How is your health in general? *

Are you allergic to ANY medicines, drugs, collagen, or chromium? *

Please List

Have you ever had ANY reaction to Novocain, Xylocaine, Adrenaline, Penicillin, other Antibiotics, Valium, Codeine, any other pain medicine or foods? *

Please List

List ALL medicines or drugs you take either regularly or occasionally: (including Rogaine, Aspirin, Motrin, Advil, or Vitamins) *

Please check on of the options: *

Please list and explain

Please list ALL medical problems

Please list ALL operations and hospitalizations with dates, including hair transplants, scalp reductions, and hair systems etc *

What is your height? *

What is your weight? *

How much alcohol do you drink per day? *

How many packs of cigarettes do you smoke per day? *

Have you had recent lab tests for HIV or Hepatitis? *

Dates and Results

Have you ever had problems healing? *

Do you have stretched scars, raised scars, thick scars, or keloids? *

Have you ever been advised by a physician or a health care provider that you should take antibiotics prior to surgical procedures? *

Have you ever had excessive bleeding during surgery? *

If you answered YES to any of the above, please specify