Hair Survey

First Name*

Last Name*

Phone*

Email*

Date of Birth*

What is your occupation?*

Street Address*

Address Line 2

City*

State*

Zip*

2. Hair / Health Profile

Have you ever been prescribed and used Propecia?

For how long? Any side effects?

Do you take any medications?

Please list medications and reason for taking.

Do you have any existing medical conditions or illnesses?

Please provide details.

Have you had a hair transplant in the past?

Please list the clinic, physician, year, procedure type and details of your previous hair transplant(s).

3. Your Hair Transplant

What do you hope to achieve with hair restoration, and what technique are you interested in?

FUE

FUT (Strip technique)

Eyebrow Restoration

PRP treatment

Facial Hair Restoration

Not Sure

Select the areas of your scalp where you need hair restoration

Have you met with other hair transplant doctors?

What treatment was recommended?

When are you thinking of scheduling your hair restoration procedure?

How did you hear about Hair of Austin at Austin Face and Body?

Add your comments!

Example

Front Photo*

Example

Top Photo*

Example

Left Photo*

Example

Right Photo*

Example

Back Photo*

By completing this form, you are giving us permission to follow-up by phone, email or text.*

1. Your Information

2. Hair / Health Profile

3. Your Hair Transplant

4. Upload your photos

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