Consultation Questionnaire

Page 1 of 4

First Name

Last Name

Email

Phone Number

Street Address

City

State

Zip Code

Gender

Birthday

Marital Status

Occupation

Ethnicity

Page 2 of 4

How did you hear about us?

Have you had any hair restoration done in the past? If so, what solution was it?

Hair TransplantTreatment (Laser Hair Therapy, PRP, Extracellular Vesicles)Non-surgical hair replacementNot sureI have not tried any hair restoration solutions

If yes to a hair transplant, when and how many sessions/number of grafts were done?

How old were you when you first noticed your hair loss?

Using the charts above, which pattern do you feel best represents your hair loss? The first chart is more applicable to men, the second chart is more applicable to women.

Using the charts above, which pattern is most predominant in your family?