First Name

Last Name

Address

City

State

Postal code

Phone *

Best time to call

Email *

PERSONAL/HEALTH INFORMATION

Age

Gender

Please list any existing medical conditions or allergies:

Any family history of baldness or thinning hair? *

Did baldness or thinning hair come about rather suddenly?(required) *

What is your time frame to proceed? *

Will you require financial assistance?(required) *

Please include any additional information, concerns or questions that will help us to better fulfil your request

PHOTO SUBMISSION

Please follow the guidelines listed below when submitting your photographs. This will allow your virtual consultation to be as close as possible to an in-person consultation.

When taking your photographs:

Do not use a flash. Instead, take the photographs in a room with bright, natural lighting.
Have the photographs taken from a distance of 3 - 5 feet.
Keep the target in focus and centered in the frame.

When submitting your photographs:

Use digital photos or print photos that have been scanned.
Use jpg or jpeg file types.
Do not exceed 4MB (4,000kb) per photograph. Larger photographs must be resized.

Front hairline

We need to be able to understand how your existing or new hairline frames your face. This is imperative for the review process. If possible, take some time to draw your hairline on your scalp to show us where you would like to have it placed. This helps us to understand your desires and expectations from the procedure.

Front hairline *

The top of your scalp
This gives us an overall view of your hair loss situation. The top view is important as it helps us determine the extent of existing hair loss and possible future hair loss.

Top of your scalp *

Oblique profile

The profile is very important in assessing the needs of our patients. The profile helps us understand the extent of hair loss.

Oblique profile *

The back of the scalp

If possible, include a photograph with your donor hair pulled up either with your hand or with a comb. This helps us determine your donor density.

The back of the scalp

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