Medical Experts In Hair Restoration
Get Back To Your Prime
Book A Consultation
Shop
$
0.00
0
Cart
Menu
Hair Transplantation
Surgical Hair Restoration
FUT (Follicular Unit Transplant)
FUE (Follicular Unit Extraction)
Eyebrow / Beard Transplants
Non Surgical Hair Restoration
Non Surgical Hair Restoration
PRP Platelet Rich Plasma
SMP (Scalp Micropigmentation)
Medical Aesthetics
Botox
Latisse
Laser Hair Removal
Process
Our Team
Gallery
Testimonials
FAQs
Shipping & Returns
Blogs
Contact
BOOK A CONSULTATION
Menu
Hair Transplantation
Surgical Hair Restoration
FUT (Follicular Unit Transplant)
FUE (Follicular Unit Extraction)
Eyebrow / Beard Transplants
Non Surgical Hair Restoration
Non Surgical Hair Restoration
PRP Platelet Rich Plasma
SMP (Scalp Micropigmentation)
Medical Aesthetics
Botox
Latisse
Laser Hair Removal
About
Our Team
Process
Gallery
Testimonials
FAQs
Shipping & Returns
Blogs
Contact
Free Consultation
1
Patient Information
2
Type of Treatment
3
Upload
Patient Name
*
First
Last
Cell #
*
Other #
Sex
*
Male
Female
Date of Birth
*
MM slash DD slash YYYY
Alberta Health Card# (if another province please specify):
*
Address
*
Street Address
City
Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Email
*
Family Doctor
Phone #
Occupation
Marital Status
Have you consulted other practitioners about your hair loss?
What is your current hair loss concern
Starting to thin
Receding hairline
Naturally high hairline
Overall thinning
Increased shedding
Advanced thinning
Bald spot forming in crown
Post pregnancy hair loss
Corrective Surgery
Scar Coverage
Beard
Eyebrow(s)
What is your personal hair restoration objectives? (check all that apply)
Hairline restoration
Crown coverage
Overall coverage
Scar coverage
Touch‐up, refinement of previous surgery
Stop hair loss/ decrease shedding
Other
Other
Where are you in your hair restoration process?
I've just started researching
I've used other hair treatments
I've had a hair transplant
I'm interested in starting non‐surgical treatment (Finasteride, Minoxidil/Rogaine, 82F, PRP)
I'm interested in scheduling a surgical procedure within the next 90 days.
I'm interested in scheduling a surgical procedure within the next year
What type of treatment are you most interested in discussing?
Non‐Surgical Options
Toppik
Platelet Rich Plasma (PRP)
Scalp Micro‐Pigmentation (SMP)
Preventative Options
Minoxidil/Rogaine
Finasteride/Propecia
82F (New Topical Solution)
Surgical Options
FUT Transplant
FUE Transplant
Corrective Surgery
Beard
Eyebrow
What stage above best matches your current situation?
None of the above, please explain?
What type of hair texture do you have?
Fine
Coarse
Curly
Straight
What type of hair density do you have?
Very Thin
Thin
Average
Above Average
What is your natural hair colour?
Blonde
Light Brown
Brown
Black
Red
Silver/Grey
Are you currently or have you previously used Propecia/Proscar/Finasteride?
Yes
No
If you stopped taking Finasteride/Propecia/Proscar, please explain why?
How long have you been experiencing hair loss?
Which of your family members have experience hair loss?
Mother
Father
Brother
Sister
Maternal Grandparent
Paternal Grandparent
Do you have any allergies?
List any medication you are currently taking:
Do you smoke regularly?
YES
NO
If yes, how much per day?
Do you drink alcohol regularly?
YES
NO
If yes, how much per day?
Are you being treated for any medical conditions at the present time or with in the past year?
YES
NO
If yes, please explain
Any additional information regarding your health you think is important for us to know?
Photo(s)
Drop files here or
Select files
Max. file size: 512 MB.
I have attached photos
FRONT
LEFT SIDE
RIGHT SIDE
TOP
BACK
OTHER
How did you find us?
Referral from Doctor
Friend
Google
Facebook
Instagram
Real Self
Online Advertisement
Print Advertisement
Δ