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Free Online Consultation Dermhair Clinic Los Angeles
FREE ONLINE HAIR TRANSPLANT AND HAIR RESTORATION CONSULTATION
1
Personal Information
2
Questionnaire
3
Upload Photos
This is not a formal consultation and it is not a substitute for an actual face-to-face history and examination by the doctor. Any response to an inquiry is tentative and subject to review after actual re-examination by the doctor.
Note that any information submitted through this form is held in strictest confidence.
Please fill out as much information as possible.
(The * marked fields are required.)
Name
*
First
Last
Preferred Contact Number:
*
Email:
*
Address:
City:
State:
Country:
Hair Color:
Age:
*
Gender:
Male
Female
1. How did you find Dr. Umar and DermHair Clinic?
*
Please Choose
Google
Yahoo
Youtube
Press Release
hairsite.com
hairlosshelp.com
hairtransplantnetwork.com
hairlosstalk.com
Other
If you chose Other, please specify below:
2. What donor source do you anticipate using? Head hair uGraft FUE only, Body hair uGraft FUE only OR a combination?
Head Hair uGraft FUE only
Body Hair uGraft FUE only
Combination
3. Have you had Hair surgery before? If yes, give details including the doctor, date, satisfaction level etc.
Yes
No
4. Have you consulted with other hair transplant or cosmetic surgeons for the same problem(s) that brings you here today? If yes, give details including doctor, date, outcome of consultation etc.
Yes
No
5. Are you currently being treated for any medical, surgical or psychological condition? If yes, please give details including medications you are currently taking etc.
Yes
No
6. Have you been treated for any medical, surgical or psychological condition in the past? If yes, please give details including medications you have taken in the past etc.
Yes
No
7. Are you using Rogaine/minoxidil, Propecia/finasteride or Avodart/dutasteride? If yes please specify which and for how long?
Yes
No
8. What are your expectations from the procedure?
9. What are your short and long term goal for hair restoration?
10. Approximate date you would prefer to have your procedure?
11. Preferred method of contact?
Phone
Email
12. Typical Male Pattern Hair loss:
Class 1
Class 2
Class 2A
Class 3
Class 3A
Class 3V
Class 4
Class 4A
Class 5
Class 5A
Class 5V
Class 6
Class 7
13. Typical Female Pattern Hair loss:
Ludwig (1,2,3,4)
Ludwig II (1,2)
Ludwig III
Advanced
Frontal
14. If your hair loss pattern does not conform to any of the above or it is caused by other disease conditions, please provide details and be sure to attach you photographs:
15. Additional questions:
Send head shots that show the balding areas. Please pull back any hair that obscures the true state of your hair line. If possible also send some photos with the entire top of the head wetted.
Include photos of the side and back of your head.
If you are having body hair transplanted, please include photos of the hair bearing areas of your body from which you want the hair taken. If you are unsure, send photos of all hair bearing areas.
Include photos of special recipient areas such as scars, eyebrows, eyelashes, moustaches etc.
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