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Please answer the following questions and email to : doctor@hairtransplant.com

1. Age?

2. Gender?

3. Are you generally in good health?

4. Are you presently under a physician’s care?

5. Have you had prior hair transplant consultation?
If yes, where? ____________________________

6. Have you had prior hair transplant procedure?
If yes, where? _____________________________
Scalp Reductions? _______ How many sessions?
Grafts ?________How many sessions?
Physician ________________________________
Any Complications?

7. Have you ever had any type of bleeding disorder (for example: easy bruising, abnormal nose-bleeds, profuse bleeding when cut)?

8. Do you have any tendency toward Keloid formation(raised, ridged scar?

9. Do you have any allergic response or adverse reaction to anesthetics or medications/drugs?

10. Do you regularly take Aspirin or Vitamin E or Gingko Biloba (a herbal supplement)?

11. Describe and list any medications and drugs you currently take: __________________________________________

12. Do you have :

Heart disease?
Hypertension?
Liver disease?
Lung disease?
Fainting spells?
Convulsion?
Venereal disease?
Diabetes?
Dizziness?

13. What's the color of your skin? Hair color? Hair texture?

14. Where do you want to have coverage: Frontal? Crown? Vertex area?

15. Thinning or bald?

16. Do you need a new hairline?

Thank you!