Consultation

Request a WebCam Consultation: Request a WebCam Consultation
How you would like *  to setup a consultation?	How you would like to setup a consultation?: * select...Email with PhotosIn Office ConsultationWebcam consultationPhone
First Name *	First Name: *
Last Name *	Last Name: *
Address	Address:
City *	City: *
State *	State: * select...AL-AlabamaAK-AlaskaAZ-ArizonaAR-ArkansasCA-CaliforniaCO-ColoradoCT-ConnecticutDE-DelawareDC-District Of ColumbiaFL-FloridaGA-GeorgiaGuamHI-HawaiiID-IdahoIL-IllinoisIN-IndianaIA-IowaKS-KansasKY-KentuckyLA-LouisianaME-MaineMD-MarylandMA-MassachusettsMI-MichiganMN-MinnesotaMS-MississippiMO-MissouriMT-MontanaNE-NebraskaNV-NevadaNH-New HampshireNJ-New JerseyNM-New MexicoNY-New YorkNC-North CarolinaND-North DakotaOH-OhioOK-OklahomaOR-OregonPA-PennsylvaniaPR-Puerto RicoRI-Rhode IslandSC-South CarolinaSD-South DakotaTN-TennesseeTX-TexasUT-UtahVI-U.S. Virgin IslandsVT-VermontVA-VirginiaWA-WashingtonWV-West VirginiaWI-WisconsinWY-WyomingOut of USA
	Other State:
Zip Code	Zip Code:
Country *	Country: * select...AustraliaBelgium and Luxembourg (Dutch)Belgium and Luxembourg (French)BoliviaBrazilBulgariaCanada (English)Canada (French)ChileColombiaCosta RicaCroatiaCzech RepublicDenmarkDominican RepublicEcuadorEl SalvadorEstoniaFinlandFranceGermanyGreeceGuatemalaHondurasHong Kong SAR (Chinese)Hong Kong SAR (English)HungaryIndiaIndonesiaIrelandIsraelJapanLatin AmericaLatviaLithuaniaMalaysiaMexicoMiddle East (Arabic)Middle East (English)NetherlandsNew ZealandNicaraguaNigeriaNorth AfricaNorwayPanamaParaguayPeruPhilippinesPolandPortugalPuerto RicoRomaniaRussiaSingaporeSlovakiaSloveniaSouth AfricaSpainSwedenSwitzerlandTaiwanThailandTurkeyUkraineUnited KingdomUnited StatesUruguayVenezuela
Daytime Phone	Daytime Phone:
Preferred Email Address*	Preferred Email Address: *
Referred By	Referred By: select...FriendGoogleMagazineMSNNewsOther Search EngineOtherSalon / Spa ProfessionalWord of MouthYahoo
Referral Details  Referral Details:
I want to schedule a  consultation with	I want to schedule a consultation with: select...Dr. Epstein - Miami, NYC, Boca Raton, TampaDr. Friedman - Phoenix/ScottsdaleDr. Galitz - Aventura, Naples
Privacy is necessary:	Privacy is necessary: Yes No
Age	Age:
Age at onset of hair loss	Age at onset of hair loss:
How fast does hair loss  currently seem to be progressing?	How fast does hair loss currently seem to be progressing?:
Medications taken for hair loss (please give dates and effectiveness):
Rogaine (minoxidil) 2%	Rogaine (minoxidil) 2%:
Rogaine (minoxidil) 5%	Rogaine (minoxidil) 5%:
Minoxidil plus Retin-A	Minoxidil plus Retin-A:
Propecia (finasteride) 1mg	Propecia (finasteride) 1mg:
Proscar (finasteride) 5mg	Proscar (finasteride) 5mg:
Other	Other:
Check Which Members of Family Have/Had Significant Hair Loss:   Check Which Members of Family Have/Had Significant Hair Loss: Father Mother Brother(s) Paternal Uncle Maternal Uncle Paternal Grandfather Maternal Grandfather Other  Other member: Indicate Your Current Hair Condition: Hairline Frontal Recession Frontal Area Mid Scalp Crown / Back Indicate Your Current Hair Condition Hairline: Normal Thinning Very Thin Bald Frontal Recession: Normal Thinning Very Thin Bald Frontal Area: Normal Thinning Very Thin Bald Mid Scalp: Normal Thinning Very Thin Bald Crown / Back: Normal Thinning Very Thin Bald Using the following diagrams, Indicate Your Current Hair Loss Pattern and the Hair Loss Pattern You Believe You May Progress To in the Future : Using the following diagrams: Men, please complete this first Hair Loss Pattern Chart. Women, please complete the one below.  Men, please complete this first Hair Loss Pattern Chart. Women, please complete the one below.   Men Chart: Current Pattern May Progress To Current Pattern May Progress To Current Pattern May Progress To Current Pattern May Progress To Current Pattern May Progress To Current Pattern May Progress To Current Pattern May Progress To Current Pattern May Progress To Current Pattern May Progress To Current Pattern May Progress To Current Pattern May Progress To Current Pattern May Progress To Women, please complete the following Hair Loss Pattern Chart. The Men's chart is above.   Women chart: Current Pattern May Progress To Current Pattern May Progress To Current Pattern May Progress To Current Pattern May Progress To Current Pattern May Progress To Indicate All the Characteristics of Your Hair:   Hair Color Hair Curl Hair Thickness Indicate All the Characteristics of Your Hair: Hair Color: Black Brown Gray Blonde Red Salt & Pepper Hair Curl: Straight Slightly Wavy Wavy Curly Hair Thickness: Fine Medium Medium Coarse Coarse Past Hair Surgery History (dates, physician/clinic, graft number): Past Hair Surgery History (dates, physician/clinic, graft number):   Please Describe Your Goals for Hair Restoration: Please Describe Your Goals for Hair Restoration: In-Depth Consult: In-Depth Consult Talking to Patients: Talking to Patients Meeting Patients: Meeting Patients Viewing a Procedure: Viewing a Procedure Frontal: Frontal: Top: Top: Side: Side: Back: Back:

Virtual Consultation

For patients who are unable to attend an in-office consultation, we provide a virtual consultation at no cost. Simply fill out the virtual consultation form and submit photographs showing your current state of hair loss.

Guidelines for Photographs

Please follow the guidelines listed below when submitting your photographs. This will allow your virtual consultation to be as close as possible to an in-person consultation.

When taking your photographs:

• Do not use a flash. Instead, take the photographs in a room with bright, natural lighting.
• Have the photographs taken from a distance of three to five feet.
• Keep the target in focus and centered in the frame.

When submitting your photographs:

• Use digital photos or print photos that have been scanned.
• Use jpg or jpeg file types.
• Do not exceed 4MB (4,000kb) per photograph. Larger photographs must be resized.
• If your photographs exceed the size limit, you may resize them by downloading PhotoResize800.exe (Windows only). After download, the PhotoResizer icon will appear on your desktop. You may then drag and drop specific photos or folders containing photos onto the icon. The PhotoResizer will then automatically resize the photos, creating smaller copies of them.

For your virtual consultation, we will require photographs showing the following angles:

1. The top of the head. A photograph showing the top of your head will provide us with an overall view of your current hair loss, including the degree of current hair loss as well as potential hair loss that may occur in the future.
2. Side profiles. Photographs showing the left and right sides, or profiles, also demonstrate the extent of hair loss.
3. The back of the head. Two photographs should be taken of the back of the head, or scalp. One should simply be a photograph of the back of the head. The other should be taken of the back of the scalp while you are pulling up a horizontal strip of hair in the donor area using your hand or a comb. This second photograph will help us to assess the density of donor hair.
4. Hairline. A photograph of the front hairline will allow use to see how your hairline frames your face. If you have an idea how you would like your hairline to look, you may demonstrate this by drawing your hairline on your scalp.

Often, our first email will go to your "spam" or "junk" mail folder. Please ensure you check this folder if you do not receive a reply from us within 24 hours.

If you live in or are visiting south Florida, a consultation needs to be scheduled. You will meet personally with Dr. Epstein in an informal yet confidential setting. An accurate assessment of your present and future hair loss pattern will be provided, and a course of treatment decided upon. Helpful staff are available to discuss financial issues. To schedule a consultation please call us at 305-666-1774, email us, or use the convenient online form above.

If you are not in the south Florida area and it is difficult for you to travel to the office for a consultation, you have other options: the Hair Loss History Questionnaire Package. When completed and mailed back to the Foundation for Hair Restoration you will be contacted by the office, and have the opportunity to speak with Dr. Epstein directly. Or, even simpler, call us at 305-666-1774 or email us, or use the form above, and a phone consultation with a quote will be arranged. You may then schedule your procedure simultaneously with your visit.  As an added service, computer imaging can also be performed on photos you send electronically to show you what to expect from a procedure.

Miami
Sunset Professional Building
6280 Sunset Drive, Suite 504
Miami, FL 33143
305-666-1774

New York City
60 East 56th Street
3rd floor
East Side Care Center
New York, NY 10022
212-759-3484

Boca Raton
Consultations and Post-Procedure Care
4800 N. Federal Highway, C100 - Sanctuary Centre
Boca Raton, FL 33431
561-750-0525

This is on Federal between Glades and Yamato.

Scottsdale
8800 East Raintree Drive, Suite 350
Scottsdale, Arizona 85260
Toll-free 305-666-1774

Tampa
We are in the process of moving meanwhile we are seeing one on one consultations with Dr. Epstein at the Renaissance Hotel (across from Neiman Marcus)
Tampa InterContinental Hotel
4860 W. Kennedy Blvd.
Tampa, FL 33609
Toll-free 305-666-1774

Jacksonville
700 3rd Street, Suite 102
Neptune Beach, FL 32266
Toll-free 305-666-1774

Los Angeles
11645 Wilshire Blvd, Suite 1100
Los Angeles, CA 90025
310-853-1585

Aventura
2875 NE 191 Street
Turnberry Plaza, Suite 303
Aventura, FL. 33180
305-666-1774
305-935-6265 fax

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