Request Hair Consultation

To schedule a virtual consultation, please fill out the form below to connect with our Hair Restoration Specialists. During your virtual consultation, our specialist will answer most of your questions and gain a clear understanding of your needs and goals. This initial step helps us tailor our approach to your unique situation. If you’re deemed a suitable candidate and wish to move forward, you’ll have the opportunity to discuss your options further with a doctor. Please rest assured that any information you share with us will be handled with the utmost confidentiality.

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1. Your Information
2. Hair/Health Profile
3. Your Hair Transplant

1. Your Information

First Name*

Last Name*

Phone*

Email*

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

Have you had a previous hair transplant?

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

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?