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Evaluation Form
HAIR LOSS
OUR SERVICES
BEFORE & AFTER
THE PROCESS
What to know
What we do
What to know
How we do it
Our Results
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First Name:*
Last Name:
 
Sex:
Male Female
DOB:
E-Mail:*
Phone:
Address:
Preferred method of Contact:
E-Mail Phone
Current level of hair loss?









Family history of hair loss?
Yes No
Are you currently using any medications or
products to treat your hair loss?		 Propecia
Minoxidil
Other:
Have you ever had a hair transplant before?
Yes No
If so, how many grafts?
What would you like to achieve with hair restoration?
Describe your hair texture:
Thin Medium Coarse
How did you hear about us?
A Friend/Patient
Search Engine
Hair Forums
Newspaper
Internet
Television

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