Hair Restoration Photo Consultation

First Name* This field is required.

Last Name* This field is required.

Phone* This field is required.

Email* This field is required.

City

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Best Time To Contact You? (Morning, Afternoon, Night)* This field is required.

Procedure of Interest This field is required.

Do you smoke?* This field is required.

Height* This field is required.

Weight* This field is required.

Date of Birth* This field is required.

When did you first notice hair loss? This field is required.

What other hair loss treatments have you tried? (Medication or topical) This field is required.

What area are you wanting to improve? This field is required.

Have you had any previous surgeries? Please include any cosmetic and non-cosmetic surgical procedures.* This field is required.

My current medications are:* This field is required.

My known drug allergies are:* This field is required.

My medical conditions are:* This field is required.

*Pictures must be uploaded with this form. Photos taken in front of a white background or clean wall are encouraged.

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Front Angle*

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Profile Angle*

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Back*

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