Hair Transplant History Questionnaire

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Transgender

Dr. Epstein also offers advice on hair transplant.

Dr. Epstein's expertise in treating
hair loss in patients of African
ethnicity was highlighted in a story
in "Sister 2 Sister" magazine.

Check out our
latest newsletter

Dr. Epstein appears
in Newsweek in
an article entitled
"A Manly Comeback"
about chest and beard
hair transplants

Consultation

Our patients come from throughout the United States (49 out of the 50 states- still looking for North Dakota) and the world. There is no charge to have a consultation through the internet by email or by a live webcam, with the surgeon of your choice.

To get the process started, you can fill out the form below, and send a few photos. A Patient Advisor will contact you promptly, to provide you with more information as well as to arrange for you to be evaluated by a surgeon. This is all conducted in a confidential and professional manner.

Patients may also have a live consultation with a Foundation for Hair Restoration doctor via the internet. Utilizing the latest in web technology, patients are able to have a live one-on-one consultation with the doctor from the privacy and convenience of their own computer. Patients can continue to be evaluated in the more traditional method of an in-person visit at one of the offices, or by telephone and email exchanges.

To have a live webcam consultation, click HERE

Our patients come from throughout the US - in this case, Craig from Hawaii.

Click on photo to enlarge

	Please send me a brochure
	Request a WebCam Consultation

How you would like
to setup a consultation?

(Required)

First Name

(Required)

Last Name

(Required)

Address

City

(Required)

State

(Required)

Zip Code

Country

(Required)

Daytime Phone

Preferred Email Address

(Required)

Referred By

I want to schedule a
consultation with

Privacy is necessary:

YesNo

Age

Age at onset of hair loss

How fast does hair loss
currently seem to be progressing?

Medications taken for hair loss (please give dates and effectiveness):

Rogaine (minoxidil) 2%

Rogaine (minoxidil) 5%

Minoxidil plus Retin-A

Propecia (finasteride) 1mg

Proscar (finasteride) 5mg

Other

Check Which Members of Family Have/Had Significant Hair Loss:
FatherMotherBrother(s)
Paternal UncleMaternal UnclePaternal Grandfather
Maternal Grandfather

Other

Indicate Your Current Hair Condition:

Hairline	Normal ThinningVery ThinBald
Frontal Recession	Normal ThinningVery ThinBald
Frontal Area	Normal ThinningVery ThinBald
Mid Scalp	Normal ThinningVery ThinBald
Crown / Back	Normal ThinningVery ThinBald

Using the following diagrams, Indicate Your Current Hair Loss Pattern
and the Hair Loss Pattern You Believe You May Progress To in the Future :

Men, please complete this first Hair Loss Pattern Chart.
Women, please complete the one below.

Current PatternMay Progress To
Current PatternMay Progress To
Current PatternMay Progress To
Current PatternMay Progress To
Current PatternMay Progress To
Current PatternMay Progress To
Current PatternMay Progress To
Current PatternMay Progress To
Current PatternMay Progress To
Current PatternMay Progress To
Current PatternMay Progress To
Current PatternMay Progress To

Women, please complete the following Hair Loss Pattern Chart. The Men's chart is above.

Current PatternMay Progress To
Current PatternMay Progress To
Current PatternMay Progress To
Current PatternMay Progress To
Current PatternMay Progress To

Indicate All the Characteristics of Your Hair:

Hair Color	BlackBrownGrayBlonde RedSalt & Pepper
Hair Curl	StraightSlightly WavyWavyCurly
Hair Thickness	FineMediumMedium CoarseCoarse

Past Hair Surgery History (dates, physician/clinic, graft number):

Please Describe Your Goals for Hair Restoration:

Virtual Consultation

For patients who are unable to attend an in-office consultation, we provide a virtual consultation at no cost. Simply fill out the virtual consultation form and submit photographs showing your current state of hair loss.

Guidelines for Photographs

Please follow the guidelines listed below when submitting your photographs. This will allow your virtual consultation to be as close as possible to an in-person consultation.

When taking your photographs:

Do not use a flash. Instead, take the photographs in a room with bright, natural lighting.
Have the photographs taken from a distance of three to five feet.
Keep the target in focus and centered in the frame.

When submitting your photographs:

Use digital photos or print photos that have been scanned.
Use jpg or jpeg file types.
Do not exceed 4MB (4,000kb) per photograph. Larger photographs must be resized.
If your photographs exceed the size limit, you may resize them by downloading PhotoResize800.exe (Windows only). After download, the PhotoResizer icon will appear on your desktop. You may then drag and drop specific photos or folders containing photos onto the icon. The PhotoResizer will then automatically resize the photos, creating smaller copies of them.

For your virtual consultation, we will require photographs showing the following angles:

The top of the head. A photograph showing the top of your head will provide us with an overall view of your current hair loss, including the degree of current hair loss as well as potential hair loss that may occur in the future.
Side profiles. Photographs showing the left and right sides, or profiles, also demonstrate the extent of hair loss.
The back of the head. Two photographs should be taken of the back of the head, or scalp. One should simply be a photograph of the back of the head. The other should be taken of the back of the scalp while you are pulling up a horizontal strip of hair in the donor area using your hand or a comb. This second photograph will help us to assess the density of donor hair.
Hairline. A photograph of the front hairline will allow use to see how your hairline frames your face. If you have an idea how you would like your hairline to look, you may demonstrate this by drawing your hairline on your scalp.

Photo Guidelines

So that we can provide the most accurate assessment possible, please use the following hair transplant photo guidelines:

Submit digital photos or scanned print photos
Use bright, natural room lighting. Do not use a flash
Shoot from a distance of 3 - 5 feet
Ensure that the area you are shooting is in frame and in focus
Photos must not exceed 4MB (4,000kb) each. Please resize photos that exceed this limit.
Acceptable photo file types are jpg or jpeg.

Provide photos showing the following angles:

Front hairline
We need to be able to understand how your existing or new hairline frames your face. This is imperative for the review process. If possible, take some time to draw your hairline on your scalp to show us where you would like to have it placed. This helps us to understand your desires and expectations from the procedure.

The top of your scalp
This gives us an overall view of your hair loss situation. The top view is important as it helps us determine the amount of existing hair loss and possible future hair loss.

Oblique profile
The profile is very important in assessing the needs of our patients. The profile helps us understand the extent of hair loss.

The back of the scalp
If possible, include a photograph with your donor hair pulled up either with your hand or with a comb. This helps us determine your donor density.

Which of the Following Would Be Most Helpful to You (Indicate All that Apply):

In-Depth ConsultTalking to Patients
Meeting PatientsViewing a Procedure

Frontal:

Top:

Side:

Back:

Often, our first email will go to your "spam" or "junk" mail folder. Please ensure you check this folder if you do not receive a reply from us within 24 hours.