Registration Page

Name

First

Last

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Date of Birth

Phone Number *

Email Address

How did you hear about us?

What type of procedure are you interested in?

Have you had any previous procedures done?

Do you have gray hair?

Do you have any bleeding disorders?

Are you alergic to any medications? If yes, please list them:

Are you currently taking any medications? If yes, list them:

Are you currently taking any medication for hair growth? (please check to indicate what you are taking)

Propecia

Rogain (Minoxidil)

Avodart

No Medications

Do you have any health problems? If yes, please list:

Have you had any surgical procedure or been hospitalized in the past? If yes, please list:

Do you have any “health habits” (i.e. alcohol, drugs, smoke)?

Your occupation

MEDICAL HISTORY: Do you or any immediate family member have any of the following conditions?

Keloids: Y/N WHO?

High Blood Pressure: Y/N WHO?

Emphysema Y/N WHO?

Thyroid: Y/N WHO?

Tuberculosis: Y/N WHO?

AIDS/HIV: Y/N WHO?

Epilepsy: Y/N WHO?

Heart Disease: Y/N WHO?

Asthma: Y/N WHO?

High Cholesterol: Y/N WHO?

Kidney Disease: Y/N WHO?

Psychiatric Care: Y/N WHO?

Sick Cell Anemia: Y/N WHO?

Skin Cancer: Y/N WHO?

Stroke: Y/N WHO?

Hepatitis: Y/N WHO?

Liver Disease: Y/N WHO?

Bronchitis: Y/N WHO?

Alcoholism: Y/N WHO?

Chemical Dependency: Y/N WHO?

For virtual appointment, we required you to fill out registration form and upload photos of your head so we can prepare your appointment. Please click on the link below. The photos must be in these five views:

Full face
Top of head
Back of head
Right side of head
Left side of head

Max. file size: 10 MB.

Email Address This field is for validation purposes and should be left unchanged.

Registration Page

MEDICAL HISTORY: Do you or any immediate family member have any of the following conditions?

Hair Transplant and Restoration

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