Hair Transplant Consultation Form Name(Required) First Last What is your age?(Required)Phone Number(Required)Email Address(Required) Preferred Contact Method(Required) Phone Email Text Hair Loss HistoryWhat age did you first notice hair loss?How long has your hair loss been progressing?Has your hair loss stabilized or is it ongoing? Stabilized Still progressing Do you have a family history of hair loss? Yes No Which areas are thinning or balding? (Check all that apply) Hairline / temples Crown (top back of head) Mid-scalp Overall thinning Beard Eyebrows Other Select AllOther(Required)Current TreatmentsHave you tried any non-surgical hair loss treatments? (Check all that apply) Minoxidil (Rogaine) Finasteride (Propecia) PRP therapy Low-level laser therapy Nutritional supplements Scalp micropigmentation Other Select AllOther(Required)Have you ever been diagnosed with alopecia areata or scarring alopecia? Yes No Surgical ConsiderationsAre you interested in ARTIS ( robotic) FUE (Follicular Unit Extraction) Have you done research about the procedure? Yes No What are your goals with hair restoration? (Check all that apply) Natural-looking hairline Filling in crown Thickening overall density Beard or eyebrow enhancement Camouflaging scarring Corrective restoration Select AllAvailability for Scheduling MeetingsWhat Day(s) is good to meet? (Select all that apply)(Required) Monday Tuesday Wednesday Thursday Friday Saturday Select AllWhat time between 8:00 AM and 5:00 PM PST time is good for you?(Required) 8:00 AM 8:30 AM 9:00 AM 9:30 AM 10:00 AM 10:30 AM 11:00 AM 11:30 AM 12:00 PM 12:30 PM 1:00 PM 1:30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM 4:00 PM 4:30 PM 5:00 PM
