First Name *

Last Name *

Email *

Street Address *

City *

State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip *

Gender * Male Female Prefer not to say

Birth Date *

Age *

Marital Status * Married Single

Occupation *

Ethnicity * American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Other American Indian or Alaska Native Prefer not to say

How did you hear about us? * TV Billboard Radio Search Engine (Google, Bing, etc.) Facebook Instagram Twitter YouTube Referral from friends, family or coworker Other

Have you had any hair restoration done in the past? If so, what solution was it? * Hair TransplantLaser Hair TherapyPRP or EVTNon-SurgicalNot SureNot Applicable

If yes to a hair transplant, 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. * Type I Type II Type III Type IV Type V 1 2 2a 3 3a 4 4a 5 5a 6 7

Using the charts above, which pattern is most predominant in your family? * Type I Type II Type III Type IV Type V Male - 1 Male - 2 Male - 2A Male - 3 Male - 3A Male - 3V Male - 4 Male - 4A Male - 5 Male - 5A Male - 6 Male - 7

Do you have any known scalp allergies or conditions? * Yes No Not Sure

Do you have any known scalp disorders? If yes, please list. *

Do you experience chronic psoriasis? * Yes No Not Sure

Have you ever used any topical solutions, medication, or other methods to reverse your hair loss? If yes, what have you tried and what were the results? *

Select all that apply. What is your main area of concern? * HairlineTopCrownOtherNot Sure

Select all that apply. Would you consider your hair to be: * DryNormalOilyDamagedThinAverageThick

Please indicate areas in which your hair loss affects you: * When I meet new peopleWhen I get dressed upMy overall appearanceWhen I see old friendsOn a windy dayIn my social lifeWhen I'm at workNone of the above

Of our hair restoration options, which are you most interested in? (Check all that apply) * Multi-Unit Hair Grafting™ Hair TransplantARTAS Robotic FUE Hair TransplantPlatelet Rich Plasma (PRP)Extracellular Vesicles TreatmentsLaser Hair TherapyNon-Surgical Hair ReplacementNot Sure

On a scale of 1-10 (10 being the most bothersome) how much does your hair loss or thinning hair bother you? * 1 2 3 4 5 6 7 8 9 10

Did you experience hair loss during pregnancy? * Yes No Not Applicable

Are you currently in hormone therapy? * Yes No

Did you tell anyone you were coming here? If yes, who? *

What concerns, if any, do you have about hair restoration? *

Have you seen a physician regarding your hair loss? * YesNo

What research have you done regarding hair loss? * Met with a physicianInternetNoneOther

What have you learned from your research? *

What is the main reason you would like to have your hair back? *

Is there a date or special occasion that you'd like to have your hair back by? *

What are your expectations for getting your hair back? *

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