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Consultation
How you would like * 
to setup a consultation? 
First Name * 
Last Name * 
Address 
City * 
State * 
Zip Code 
Country * 
Daytime Phone 
Preferred Email Address* 
Referred By 
I want to schedule a 
consultation with 
Privacy is necessary: 
   
Age 
Age at onset of hair loss 
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) 5% 
Minoxidil plus Retin-A 
Propecia (finasteride) 1mg 
Proscar (finasteride) 5mg 
Other 

Check Which Members of Family Have/Had Significant Hair Loss:
 
Other 

Indicate Your Current Hair Condition:
Hairline
Frontal Recession
Frontal Area
Mid Scalp
Crown / Back
Indicate Your Current Hair Condition

Using the following diagrams, Indicate Your Current Hair Loss Pattern
and the Hair Loss Pattern You Believe You May Progress To in the Future :

 Men, please complete this first Hair Loss Pattern Chart.
Women, please complete the one below.

 

Women, please complete the following Hair Loss Pattern Chart. The Men's chart is above.
 

Indicate All the Characteristics of Your Hair:
 
Hair Color
Hair Curl
Hair Thickness
Indicate All the Characteristics of Your Hair:
Past Hair Surgery History (dates, physician/clinic, graft number):
 
Please Describe Your Goals for Hair Restoration:
Frontal:
Top:
Side:
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 1-800-370-2883, 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 1-800-370-2883 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
305-666-1774 or toll-free 1-800-370-2883
Sunset Professional Building
6280 Sunset Drive, Suite 504
Miami, FL 33143

Boca Raton
561-750-0525 or toll-free 1-800-370-2883
4800 N. Federal Highway, C100 - Sanctuary Centre
Boca Raton, FL 33431

This is on Federal between Glades and Yamato.

New York
(212) 759-3484 or toll-free 1-800-370-2883
60 East 56th Street
3rd floor
East Side Care Center
New York, NY 10022

Tampa
We are in the process of moving meanwhile we are seeing one on one consultations with Dr. Epstein at the InterContinental Hotel

Tampa InterContinental Hotel
4860 W. Kennedy Blvd.
Tampa, FL 33609
Toll free 1-800-370-2883

Los Angeles
11500 W. Olympic Boulevard, Suite 315
Los Angeles, CA  90064
800-370-2883

Westborough
2 Connector Road, Suite 2C
Westborough, MA 01581
800-370-2883

German Office
Peter-Dassis-Ring 33
57482 Wenden
Germany

Like what you have seen?  To learn even more, click here to visit the Foundation for Hair Restoration

  Email Dr. Epstein below
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