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 AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe 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 * NameThis field is for validation purposes and should be left unchanged.
