Consult Form – Restorative Therapeutic Hair Loss Control & HAIR Replacements Services

Name *

First

Last *

Last

Address

City

State/Province

Zip/Postal

Date of Birth

Age

Phone

Email *

Allergies

Are You Allergic to Shellfish?

No

Yes

General Health?

Previous Surgery's with General Anesthesia?

Do You Have Any of the Following Medical Problems?

Presently Undergoing Medical Treatment For?

Physician's Name

Date of Last Physical

Stress

High

Medium

Low

Bloodwork if done within the past Year?

Currently Taking any Medications? *

Male or Female?

Female

Male

Females Only

Female Issues

Yes

No

Post-Menopausal

Yes

No

Are You Planning to Get Pregnant within the next 6 Months?

Yes

No

Are you Currently Pregnant or Nursing?

Yes

No

Do You Take Contraceptive Pills?

Yes

No

How Long Have You Take Them?

Males Only

Have You had or plan to take a PSA blood test for the screening of prostate cancer?

Yes

No

Do you have an enlarged prostate, prostate cancer?

Yes

No

Nutrition

Are You a Vegetarian?

Yes

No

How Many Daily Servings of Protein do You Get?

Weight Loss Recently?

No

Yes

How Much?

Hair & Scalp Conditions

Scalp

Normal

Dry

Oily

Dandruff

No

Yes

Any Redness or Itchiness on Scalp?

No

Yes

Do You Pull Your Hair?

No

Yes

Any Bumps or Raised Areas?

No

Yes

Recurrent attacks of patchy hair loss?

No

Yes

Hair of Different Lengths?

No

Yes

Areas of Hair Loss?

All Over Scalp

Front

Crown

At What Age Did you Notice Hair Loss?

Time Frame

Gradual

Sudden

What Kind of Shampoo Do You Use?

What Kind of Conditioner Do You Use?

How Many Times Per Week Do You Shampoo?

Do You Use a Hair Dryer?

Yes

No

What Temperature?

Hot

Medium

Cool

When hair is wet, do you use a towel to rub dry?

Yes

No

Is your hair loss concern caused by any medical problems or medications that you are aware of?

Heredity

Does Hair Loss Run in Your Family?

Yes

No

Parents

Bald

Thinning

Not Bald

Unknown

Grandparents

Bald

Thinning

Not Bald

Unknown

Sibilings

Bald

Thinning

Not Bald

Unknown

Aunt

Bald

Thinning

Not Bald

Unknown

Uncle

Bald

Thinning

Not Bald

Unknown

What options have you researched for your hair loss (Including over the counter and prescriptions)?

How Much Does Your Hair Loss Bother You?

Slightly

Moderately

Very Much

Did You Tell Anyone that You're Coming Here?

Yes

No

Would you like to consider using prescription topicals and pills if you could get better results? Keep in mind, prescription products in general increase the cost of the program?

Yes

No

What are your goals and expectations?

Prevent further loss

Gradually gain back some hair

Gain back hair quicker

OtherOther

Knowing that treatment and/or surgical options may take 6 months or more to show success, are you willing to wait that long?

Yes

No

Please indicate the situations in which your hair loss bothers you the most

Consent for treatment

I am being evaluated at the Hair Loss Management Center (HLMC) and understand that I will first undergo a comprehensive preliminary evaluation by one of our AMCA and USTI Certified Trichologists, Hair Loss Practitioners and Associate Trichologists. I understand that the cost of the initial evaluation is reduced from $250 to $150 consultation fee, all of which will go toward any programs purchased. All other checkups are free of charge for the first year with a purchase of over $499.00. This preliminary evaluation will include a complete and thorough hair loss questionnaire, a scalp evaluation including standard photography (with face hidden) and microscopic photography. Further evaluation will consist of monthly or quarterly digital and capilloscope pictures for which I give my consent. I further understand that although HLMC has had many successful clients, each client is different and like any cosmetic treatment, results will vary depending on many factors. I acknowledge that it is my responsibility to inform HLMC of any changes in my health condition no matter how minor.

Signature

Disclaimer: The information provided in this document is for informational purposes only. The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Clients should always seek the advice of their physician or other qualified health care professionals who are familiar with the patients’ medical history for any questions concerning a medical condition. Although our certified trichologists, hair loss practitioners and associate trichologists are trained and knowledgeable they are not medical professionals and therefore can only make cosmetic recommendations. If you wish to be referred to a doctor, HLMC will make a reference.

Date