Short Form
Please Fill out and upload
5 pictures of problem area
HIPAA compliant privacy policy system
SalesForceID
Have you had any allergies or medical issues? If so, please explain them below:
Yes
No
Allergies or Medical Issues
Has the patient tested positive for Hepatitis C?
*
No
Yes
Has the patient tested positive for HIV?
*
No
Yes
When did you first begin noticing the loss of hair?
Before 20 years of age
Between 20-40 years of age
After 40 years of age
What are you trying to achieve?
Cover a few problematic areas
Full hair like before the hair-loss began
Grow long hair
Have you done any other type of hair loss treatment before?
Yes
No
What type of treatment did you do?
Hair-loss natural products
Hair-loss medication
FUE somewhere else
FUT somewhere else
How long ago was this treatment done?
Less than 6 months ago
7 to 24 months ago
More than 3 years ago
Tutorial
Please upload 5 pictures regardless of the problematic areas you want to cover so that our medical team can make an accurate evaluation (see images for guidance on how to take pictures).
*
Submit
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