Hair Loss History Survey

If you are a human, do not fill in this field.

1. Your Information

First Name*

Last Name*

Phone*

Email*

Date of Birth*

What is your occupation?*

Street Address*

Address Line 2

City*

Province*

Postal Code*

Country*

2. Hair / Health Profile

What age did you first notice hair loss?

Are you currently, or have you ever taken Propecia?

For how long? Any side effects?

Are you currently, or have you ever taken Rogaine?

For how long? Any side effects?

Have you ever tried Platelet Rich Plasma (PRP) treatments?

Please Explain

Do you take any other medications?

Please list medications and reason for taking

Do you have any pre-existing medical conditions?

Please provide details

Do you smoke?

How much?

Have you had a previous hair transplant?

Please list the clinic, physician, year, procedure type and details of your previous hair transplant.

Describe the hair loss on your mother’s side of the family

Describe the hair loss on your father's side of the family

Describe the hair loss of your sibling(s)

3. Your Hair Transplant

What are your overall goals and objectives with your hair restoration procedures?

FUE

Strip technique (FUT)

Eyebrow Restoration

PRP treatment

Facial Hair Restoration

Unsure

Select the zones on your scalp you want to have treated

(proceed to next question if you are not seeking scalp hair restoration)

(Click the image to view to its full size)

Front

Top

Small Crown

Expanded Crown

Have you consulted with another hair transplant doctor?

What treatment was recommended?

When are you thinking of scheduling your hair restoration procedure?

How did you hear about us?

Any other comments?

4. Upload your photos

Total size of image attachments must not exceed 20 megabytes.

Front Photo

Example

Top Photo

Example

Left Photo

Example

Right Photo

Example

Back Photo

Example