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Photo Consult for Hair Loss

Note: In-person consultations are preferred because an exam allows the doctor to better evaluate your hair loss. Schedule a consult at our office with Dr. Bernstein or Dr. Shah.

Can’t visit our hair restoration facility in New York City? Use our photo consultation service! Fill out the form below as completely as possible.

After reviewing the information and photos you submit, the doctor will contact you by e-mail. All information and photos that you supply are kept strictly confidential.

Photos may only be submitted as JPGs and must be under 6 megabytes in size.

* = required

Personal Information

First Name *
Last Name *
Email Address *
Phone Number
Mailing Address
Apartment or P.O. Box
City *
State/Province *
Postal Code
Country *
Current Age *
Gender *

Purpose of Inquiry

The purpose of your inquiry is to find out about?
(Please check ALL that apply)
Cause of Hair Loss
Medication for Hair Loss
Hair Transplant
FUT
FUE
Hair Transplant Repair

Hair Loss Info

What are your goals for your hair restoration?
Have you had any hair transplant procedures or other hair restoration surgery? If so, please provide as much detail as possible including dates and type of procedure.
Please list any relevant surgical procedures you have had that might affect a hair transplant procedure (i.e. keloid formation, bleeding disorder).
Please list any relevant medical conditions you have or had that might affect a hair transplant procedure (i.e. diabetes).
Date you started treatment with Propecia
Date you started treatment with Rogaine
Other medications you are taking

Photo Uploads

Instructions: Please take photos with your hair dry. Include your entire head. You may block out your face, but a very close-up photo is of little value. The doctor needs to see the overall pattern of your hair loss.
Front View
Angle or Side View
Top View
Rear View

General Info & Comments

How Did You Hear About Bernstein Medical? *
Other Referral?
Comments

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