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                                                                    What have you done to learn about hair loss? 
                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                        
                                                                    How did you hear about us? 
                                                                                                                                                                                                                                                                
                                                             
                                                                                            
                                                                                                                                                                                                
                                                                    What was it that convinced you to consider us for your hair transplant? 
                                                                                                                                                                                                                                                                
                                                             
                                                                                                                                
                                                                                                                                                                                                
                                                                    Are you currently taking Propecia? 
                                                                                                                                                                                                    
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                                            Yes 
                                                        No 
                                                                                         
                                                             
                                                                                                                                
                                                                                                                                
                                                                                                                                                                                                
                                                                    Are you currently taking Rogaine? 
                                                                                                                                                                                                    
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                                            Yes 
                                                        No 
                                                                                         
                                                             
                                                                                                                                
                                                                                                                                
                                                                                                                                                                                                
                                                                    Do you take any other medications? 
                                                                                                                                                                                                    
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                                            Yes 
                                                        No 
                                                                                         
                                                             
                                                                                                                                
                                                                                                                                                                                                
                                                                    Please list medications and reason for taking 
                                                                                                                                                                                                                                                                
                                                             
                                                                                                                                
                                                                                                                                                                                                
                                                                    Do you have any pre-existing medical conditions? 
                                                                                                                                                                                                    
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                                                                    Do you smoke? 
                                                                                                                                                                                                    
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                                            Yes 
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                                                                    Have you had a previous hair transplant? 
                                                                                                                                                                                                    
    Please Select 
                                            Yes 
                                                        No 
                                                                                         
                                                             
                                                                                                                                
                                                                                                                                                                                                
                                                                    Please list the clinic, physician, year, procedure type and details of your previous hair transplant. 
                                                                                                                                                                                                                                                                
                                                             
                                                                                            
                                                                                            
                                                                                                                                                                                                
                                                                    Select the zones on your scalp you want to have treated. 
                                                                                                                                                                                                        
    
                                                             
                                                             
                                                                                                                                
                                                                                                                                                                                                
                                                                    Have you consulted with another hair transplant doctor? 
                                                                                                                                                                                                    
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                                            Yes 
                                                        No 
                                                                                         
                                                             
                                                                                                                                
                                                                                                                                                                                                
                                                                    What treatment was recommended? 
                                                                                                                                                                                                                                                                
                                                             
                                                                                            
                                                                                                                                                                                                
                                                                    When are you thinking of scheduling your hair restoration procedure? 
                                                                                                                                                                                                    
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                                            Less than 1 month 
                                                        1-3 months 
                                                        3-6 months 
                                                        6-12 months 
                                                        Not sure 
                                                                                         
                                                             
                                                                                            
                                                                                                                                                                                                
                                                                    What are you most interested in learning more about?