Please take a moment to complete all fields and required information in the forms below, including your hair restoration goals and any questions you have. If you have questions or any trouble completing the form, please email us at:
* Please complete all fields to receive a faster and more in-depth consultation response.
1.Age:
(Required)
Gender:
(Required)
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 closest to your
hair loss condition when your hair is wet: (Required)
8. At what age did you begin
to notice hair loss? (Required)
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)? (Required)
10. Have you consulted with a
doctor about your hair loss condition?
With Whom?
11. What treatment, if any, was recommended?
12. Have you ever had surgical
hair restoration performed?
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?
(Required)
15. What is your family hair loss history?
Please add any additional questions or comments:
Upload Your Photos
Please ensure you upload photos that are clear and capture all of the views shown in the examples below:
It is helpful if you rename the images to describe the angles. (Example – “front.jpg” or “crown.jpg”).
Please wet and comb your hair back for the front view photo.
Max upload= 32MB
Max upload file size= 5MB
Picture1:
Picture2:
Picture3:
Picture4:
Picture5:
Picture6:
Picture11:
Picture12:
Picture13:
Picture14:
Picture15:
Picture16:
Your Contact Information
Note-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: (Required)
Last Name: (Required)
Email Address: (Required)
Street Address
Line 1: (Required)
Street Address Line 2:
City: (Required)
Country: (Required)
State/Province:
Zip Code: (Required)
Phone:
I prefer to be contacted by:
Preferred Procedure: Required
How did you
hear about us? Required
NOTE!
The information in this form will be submitted using your
email application on your machine. The page will not change
after the form has been submitted.
