CLICK HERE TO RETURN TO HOME PAGE OF SITE Are PRP hair injections for you? Fill out our Hair Loss History Form Please enable JavaScript in your browser to complete this form.Date / TimeDateTimeName *FirstLastCell Phone Number *Email *What is your date of birth? *Are you a male or female?FemaleMaleHow long have you had hair loss?Where is your hair loss? *Front hairlineCrownTemplesDiffuse-all over scalpSidesBack of headHave your tried anything for hair loss?YesNoIf yes, what have you tried?Do you have any medical problems? This is important. Medical conditions can affect your hair. YesNoIf yes, please list your medical problems. Please list your medicationsPlease list any supplements that you are takingHave you ever worn hairstyles that put tension on the scalp-weaves, braids, cornrows or a ponytail?YesNoDoes your current hair style put tension on any areas of the scalp?YesNoIf you are wearing a high tension style, are you willing to give that up in order to grow your hair.?YesNoDoes hair loss run in your family?YesNoLow Vitamin D is very common and can affect hair. Have you had a Vitamin D test?YesNoDo you think hormone imbalances are affecting your hair?YesNoHave you ever had PRP injections for hair before?YesNoWould you like to set up a Virtual consultation about PRP hair? To book, please text pictures to 770-649-0094 YesNoCustom Captcha * = WebsiteSUBMIT CLICK HERE TO RETURN TO HOME PAGE OF SITE
