Note - This form, and any reply to it, does not take the place of an actual in person consultation. It is merely intended to provide the clinics your are interested in with an initial idea of your condition and goals. With this information they can then give you an informed reply.
1.Your Age:
Gender: Male Female
2. What color is you hair?
Black / Dark Brown Gray
Med Brown Light Brown / Blond / Red
3. Which best describes your natural hair?
straight wavy
curly
4. What is the texture of your hair?
fine medium
thick
5. Click on the image closest to your hair loss condition when your hair is wet.
6. At what age did you begin to notice hair loss?
< 20 21-30 31-40
41-50 50 >
7. What would you like to achieve with hair transplantation (restore the front hairline, mid scalp, back, or your entire balding area)?
8. Have you consulted with a doctor about your hair loss condition?
Yes
No
With Whom?
9. What treatment, if any, was recommended?
10. Have you ever had surgical hair restoration performed?
If so, with whom?
11. Have you treated your hair loss with any of the following?
Rogaine
Past
Present
Saw Palmetto
Propecia
Other
Feel free to send your comments or questions:
Your Contact Information
Street Address Line 2:
Country: required
Day Phone:
Evening Phone:
- Check this if you wish to be called
Email Address: required
I prefer to be contacted by:
email phone either
Hair Restoration information on this site has been contributed by hair loss specialists and surgeons who have years of experience in the field of hair restoration.
Hair Transplants: How do Hair Transplants Work? The Reason for Using Only Follicular Units How is Follicular Unit Transplantation Different from Mini-Micrografting?
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