History Consultation Request a WebCam Consultation How you would like to setup a consultation*select...PhoneEmail with PhotosWebCam ConsultationIn Office ConsultationFirst Name:*Last Name:*Street: Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Daytime Phone:Preferred Email Address:* Referred byselect...FriendGoogleMagazineMSNNewsOther Search EngineOtherSalon / Spa ProfessionalWord of MouthYahooPrivacy is necessaryYesNoAge:Age at onset of hair lossHow 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-APropecia (finasteride) 1mgProscar (finasteride) 5mgOtherCheck Which Members of Family Have/Had Significant Hair Loss Father Mother Brother(s) Paternal Uncle Maternal Uncle Paternal Grandfather Maternal Grandfather Other Indicate Your Current Hair Condition:HairlineNormalThinningVery ThinBaldFrontal RecessionNormalThinningVery ThinBaldFrontal AreaNormalThinningVery ThinBaldMid ScalpNormalThinningVery ThinBaldUsing 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 belowCurrent PatternMay Progress ToCurrent PatternMay Progress ToCurrent PatternMay Progress ToCurrent PatternMay Progress ToCurrent PatternMay Progress ToCurrent PatternMay Progress ToCurrent PatternMay Progress ToCurrent PatternMay Progress ToCurrent PatternMay Progress ToCurrent PatternMay Progress ToCurrent PatternMay Progress ToCurrent PatternMay Progress ToWomen, please complete the following Hair Loss Pattern Chart. The Men's chart is above.Current PatternMay Progress ToCurrent PatternMay Progress ToCurrent PatternMay Progress ToCurrent PatternMay Progress ToCurrent PatternMay Progress ToIndicate All the Characteristics of Your Hair:Hair ColorBlackBrownGrayBlondeRedSalt & PepperHair CurlStraightSlightly WavyWavyCurlyHair ThicknessFineMediumMedium CoarseCoarsePast Hair Surgery History (dates, physician/clinic, graft number):Please Describe Your Goals for Hair Restoration: In-Depth Consult Talking to Patients Meeting Patients Viewing a Procedure Frontal:Top:Side:Back:* I accept the Terms of Use *
