Home » Contact Us » Photo Consult

Photo Consult

Note: In-person consultations are always preferred, because an in-person exam allows the doctor to more thoroughly diagnose your hair loss. Click here to schedule a hair loss evaluation with Dr. Bernstein.

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, Dr. Bernstein 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.

Personal Information

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

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

Front View
Angle or Side View
Top View
Rear View

General Info & Comments

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

Please verify that this is a legitimate inquiry

The opposite of up is

cforms contact form by delicious:days