Please enable JavaScript in your browser to complete this form.Date / TimeDateTimeName *FirstLastEmail *Cell Phone Number *What treatments have you had for your hair?Have you seen any improvement in your hair?If yes, please descrobe. What kind of thinning do you have?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? 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 medicationsDo you have any allergies to any medications?YesNoIf yes, what are you allergic to?Please 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?YesNoAre you a vegetarian?YesNoLow Vitamin D is very common and can affect hair. Have you had a Vitamin D test? *YesNoWhen was the last time you had routine bloodwork done?Have you had your thyroid tested in the past year?YesNoIf you are a female, have you gone through menopause?YesNoCustom Captcha * = EmailSUBMIT
