Personal Information

Date *

Full Name *

Address

Street Address *

City

State

Country

Postal code

Email *

Phone *

Date of birth (Please click on the field to pick the date) *

Marital Status

Partner's First Name *

Occupation

Employer

Referral Information

How did you hear about Hair Restoration Centers ? *

Referral Name (If any)

Hair Loss History

How old were you when you first noticed Hair loss? *

Please detail any hair loss in other family members *

Medical History

Are you generally in good health? *

Yes

Are you presently under Doctor's care? *

Yes

Have you had prior hair transplants? *

Yes

If yes, please complete the following questions. If no, you can skip to the next page

How many previous hair transplants?

When was your last hair transplants?

Was it a strip or FUE?

How many grafts?

Who was the surgeon?

Anesthesia & Allergies

Do you regularly take abnormal amounts of aspirin? *

Yes

Do you have any allergic response or adverse reaction to drugs or medications? *

Yes

Substance Use

Have you ever been treated for drugs(Prescription or non prescription) or alcohol abuse ? *

Yes

If yes please describe:

Do you smoke or use tobacco? *

Yes

If yes - How often?

Medications & Supplements

List present drugs and medications taken or prescribed :

List any vitamin or nutritional supplements you are taking :

Upload Photos (Front, Back, Top of Head)

Have you already uploaded the photos? (If yes please skip the photos)

Yes

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.

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

Oblique profile

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

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.

Personal and Confidential Client Profile

Signature *

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Date