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Hair Transplant Consultation Form
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About Us
Hair Transplant Consultation
Personal Information
Name
(Required)
First
Last
What is your age?
(Required)
Phone Number
(Required)
Email Address
(Required)
Preferred Contact Method
(Required)
Phone
Email
Text
Hair Loss History
What age did you first notice hair loss?
How long has your hair loss been progressing?
Has your hair loss stabilized or is it ongoing?
Stabilized
Still progressing
Do you have a family history of hair loss?
Yes
No
If yes, when and where?
(Required)
Which areas are thinning or balding? (Check all that apply)
Hairline / temples
Crown (top back of head)
Mid-scalp
Overall thinning
Beard
Eyebrows
Other
Other
(Required)
Current Treatments
Have you tried any non-surgical hair loss treatments? (Check all that apply)
Minoxidil (Rogaine)
Finasteride (Propecia)
PRP therapy
Low-level laser therapy
Nutritional supplements
Scalp micropigmentation
Other
Select All
Other
(Required)
Have you ever been diagnosed with alopecia areata or scarring alopecia?
Yes
No
Surgical Considerations
Are you interested in:
ARTIS ( robotic)
FUE (Follicular Unit Extraction)
Have you done research about the procedure?
Yes
No
What are your goals with hair restoration? (Check all that apply)
Natural-looking hairline
Filling in crown
Thickening overall density
Beard or eyebrow enhancement
Camouflaging scarring
Corrective restoration
Select All
Availability for Scheduling Meetings
What Day(s) is good to meet? (Select all that apply)
(Required)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Select All
What time between 11:00 AM and 4:00 PM EST time is good for you?
(Required)
11:00 AM
11:30 AM
12:00 PM
12:30 PM
1:00 PM
1:30 PM
2:00 PM
2:30 PM
3:00 PM
3:30 PM
4:00 PM
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+1 840 841 25 69
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