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 *FirstLastAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCell 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 headOtherIf other, please give details about the area. Do you have areas of hair loss that are smooth without any hair?YesNoIf yes, what area or areas? (copy)Have you ever been evaluated for hair loss?YesNoIf yes, what were you told about the cause of your hair loss?Have 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 been told that your polycystic ovaries or insulin resistance?YesNoHave you ever had PRP injections for hair before?YesNoWould you like to set up a Virtual consultation about PRP hair? If yes, PLEASE TEXT PICTURES OF YOUR HAIR to 770-649-0094 and make sure to have read thru the site thoroughly. YesNoWe want to be respectful of your time and the doctor's time. Did you read the site completely and see the Package pricing? *YesNoCan we text you?YesNoCustom Captcha * = PhoneSUBMIT CLICK HERE TO RETURN TO HOME PAGE OF SITE
