Schedule A Physician Consultation Today

We are pleased to offer three types of consultations:

In-office Consultation: An appointment with a physician in our physical office.
This is preferred because it allows your physician to examine you and make specific recommendations regarding medication and surgery.
Virtual Consultation: A video visit with a physician.
This is available to new and existing patients who cannot make it to our NYC office. Virtual consultations may not be recommended for every type of hair loss.
Surgical Photo Assessment: Preliminary photo evaluation for hair restoration surgery via email (complimentary).

Please note that virtual consultation and photo assessments do not substitute for an in-office consultation which is often required for surgery. All consultations, in any form, are confidential.

Please refer to our Consultation Fees & Hair Transplant Cost page for fee details.

Please fill out the information below or call our office 212.826.2400

Gender*
Please indicate the type of consultation you are interested in:*
- In-office Consultation
- Virtual Consultation
- Surgical Photo Assessment
First Name*
Last Name*
Email*
Phone Number*
Date of Birth*
MM slash DD slash YYYY
How would you like to be contacted?*
- Email
- Phone
Comments
How did you hear about Bernstein Medical?
Check box to receive email updates from Bernstein Medical
- Check box to receive email updates from Bernstein Medical
Patient History
(If any aspect of your health changes in the future, please let us know)
Are you a new patient or contacting for a follow up visit?
- New Patient
- Follow Up Visit
Address
Street Address City State / Province / Region ZIP / Postal Code Country
1. What is the main purpose of your visit?*
- Hair Loss
- Medical Treatment
- Surgical Treatment
- Robotic FUE
- FUT
- Eyebrow Restoration
- Repair
- Scar Revision
- PRP
- Other
1. What is the main purpose of your visit?*
- Hair Loss
- Medical Treatment
- Surgical Treatment
- Robotic FUE
- FUT
- Eyebrow Restoration
- Repair
- Scar Revision
- PRP
- Other
1. What is the main purpose of your visit?*
- Hair Loss
- Medical Treatment
- Surgical Treatment
- Robotic FUE
- FUT
- Eyebrow Restoration
- Repair
- Scar Revision
- PRP
- Other
Other hair loss/restoration consults and approximate dates:
Other hair loss/restoration consults and approximate dates:
Other hair loss/restoration consults and approximate dates:
Have you had previous Hair Restoration Surgery? If yes, please provide details including years.*
2. Have you had previous Hair Restoration Surgery? If yes, please provide details including years.*
2. Have you had previous Hair Restoration Surgery? If yes, please provide details including years.*
2. At approximately what age did your hair loss begin?
3. At approximately what age did your hair loss begin?
3. At approximately what age did your hair loss begin?
3. Do you have any known allergies?
- Yes
- No known allergies
4. Do you have any known allergies?
- Yes
- No known allergies
4. Do you have any known allergies?
- Yes
- No known allergies
Please check the appropriate:
- Antibiotics
- Novocain or Xylocaine
- Adrenaline
- Valium
- Codeine
- Food Allergies
- Hay Fever/Upper Respiratory
- Chromium or Collagen
- Other Allergy not listed
Please list.
Please specify other allergy/allergies not listed above.
4. What type of Allergic reactions have you had?
- Hives
- Respiratory
- Heart Palpitations
- Swelling of tongue
- Rash
- Coughing & Congestion
- Difficulty Breathing
- Other reactions
- None
5. What type of Allergic reactions have you had?
- Hives
- Respiratory
- Heart Palpitations
- Swelling of tongue
- Rash
- Coughing & Congestion
- Difficulty Breathing
- Other reactions
- None
5. What type of Allergic reactions have you had?
- Hives
- Respiratory
- Heart Palpitations
- Swelling of tongue
- Rash
- Coughing & Congestion
- Difficulty Breathing
- Other reactions
- None
Please specify other reactions experienced:
5. Are you currently using finasteride (Propecia)?*
- Yes
- No
Start date*
MM slash DD slash YYYY
6. Are you taking any other medications?
- Yes
- No
Please list.
7. Have you ever had the following medical or health problems?
- Hepatitis or Liver Disease
- Kidney Problems
- Diabetes
- Asthma
- High Blood Pressure
- Heart Disease
- Irregular Heart Beats
- Rheumatic Fever
- HIV/AIDS
- Anemia
- Thyroid Disease
- Phlebitis
- Ulcers
- Glaucoma
- Seizures
- Sleep Apnea
- Fainting
- Blood Disorders
- Other
- None of the above
Please explain:
8. Do you have any of the following?*
- Anxiety
- Depression
- Panic Disorder
- Obsessive Compulsive Disorder (OCD)
- Body Dysmorphic Disorder (BDD)
- Hypochondriac
- Other Emotional/Drug/Psychiatric Problems
- None of the above
Please explain:
9. Do you have any history of sexual dysfunction?
- Occasional
- Intermittent
- Persistent
- None
10. Have you or anyone in your family had prostate disease or prostate cancer?
- Yes
- No
Please describe:
11. Have you had a recent PSA (prostate specific antigen test):
- Yes
- No
Indicate PSA number (if known)
Date of Test
MM slash DD slash YYYY
12. Have you ever been hospitalized for any other (non-hair transplant) surgery?
- Yes
- No
Please list all medical problems and hospitalizations:
13. What % of your day do you think about hair?
- <5%
- 5
- 10
- 20
- 30
- 40
- 50
- 60
- 70
- 80
- 90
- 100%
14. Do you suffer from any of the following scalp conditions?
- Sensitivity
- Itching
- Tingling
- None of the above
15. When was the last time you washed your hair?
- Today
- Yesterday
- 2 days ago
- 3 days ago
- More than 3 days ago
16. What is your height?

Please specify in feet and inches
17. What is your weight?

Please specify in lbs
18. Are you married?
- Yes
- No
19. How many children do you have?
20. Do you consume alcohol?
- Yes
- No
Describe how much alcohol is consumed per day
21. Do you smoke?
- Yes
- No
If Yes, how much?
22. Have you had Lab tests for Hepatitis?
- Yes
- No
If Yes, results:
23. Have you had a recent HIV Test?
- Yes
- No
If Yes, results:
24. Have you ever had problems healing?
- Stretched Scars
- Raised or thickened scars
- Keloids
- No known problems with healing
25. Have you ever been advised to take antibiotics prior to surgery or dental work?
- Yes
- No
Please specify
26. Have you ever had excessive bleeding during surgery or at other times?
- Yes
- No
Please specify
27. Have you ever had a MRSA Infection?
- Yes
- No
Please specify
28. Have you ever had cervical disc or other neck problems?
- Yes
- No
Please give details
6. Are you currently using any medications for hair loss?
- Yes
- No
6. Are you currently using any medications for hair loss?
- Yes
- No
Please list.
7. Are you currently taking any of the following medications?
- Blood thinners (warfarin, heparin)
- Seizure medications (Dilantin)
- Gout (colchicine, alopurinol)
- Blood pressure medications (beta blockers, water pills)
- Thyroid Synthroid, L-Thyroxine)
- Anti-Inflammatories (prednisone)
- Cholesterol Lowering Lipitor)
- Oral contraceptives
- Fertility medications
- Hormones
- Psychiatric medications (i.e.: Lithium, anti-depressants, Prozac)
- Cocaine
- Amphetamines
- Other medications or drugs
7. Are you currently taking any of the following medications?
- Blood thinners (warfarin, heparin)
- Seizure medications (Dilantin)
- Gout (colchicine, alopurinol)
- Blood pressure medications (beta blockers, water pills)
- Thyroid Synthroid, L-Thyroxine)
- Anti-Inflammatories (prednisone)
- Cholesterol Lowering Lipitor)
- Oral contraceptives
- Fertility medications
- Hormones
- Psychiatric medications (i.e.: Lithium, anti-depressants, Prozac)
- Cocaine
- Amphetamines
- Other medications or drugs
8. Do you have any of the following dietary habits?
- Crash diets
- Anorexia
- Bulimia
- Vegetarian
- Other Special Diet
8. Do you have any of the following dietary habits?
- Crash diets
- Anorexia
- Bulimia
- Vegetarian
- Other Special Diet
Please describe.
9. Do you use any of the following hair care systems?
- Perms
- Flat Iron Straightening
- Chemical Straightening or relaxer
- Braiding
- Hair Extensions
- Wigs
- Hair Systems
9. Do you use any of the following hair care systems?
- Perms
- Flat Iron Straightening
- Chemical Straightening or relaxer
- Braiding
- Hair Extensions
- Wigs
- Hair Systems
10. How often do you wash/shampoo your hair?
10. How often do you wash/shampoo your hair?
11. When was the last time you washed/shampooed your hair?
11. When was the last time you washed/shampooed your hair?
12. Have you ever had the following medical or health problems?
- Anemia
- Iron Deficiency
- B12 Deficiency
- Autoimmune Disease
- Significant Weight Change
- Increased Sweating
- Increased Feeling of Being Hot or Cold
- High Fever
- Joint Pain
- Sensitivity to Sunlight
- Hepatitis or Liver Disease
- Kidney Problems
- Diabetes
- Asthma
- High Blood Pressure
- Heart Disease
- Irregular Heart Beats
- Rheumatic Fever
- HIV/AIDS
- Thyroid Disease
- Phlebitis
- Ulcers
- Glaucoma
- Seizures
- Sleep Apnea
- Fainting
- Anemia
- Blood Disorders
- Other
- None
12. Have you ever had the following medical or health problems?
- Anemia
- Iron Deficiency
- B12 Deficiency
- Autoimmune Disease
- Significant Weight Change
- Increased Sweating
- Increased Feeling of Being Hot or Cold
- High Fever
- Joint Pain
- Sensitivity to Sunlight
- Hepatitis or Liver Disease
- Kidney Problems
- Diabetes
- Asthma
- High Blood Pressure
- Heart Disease
- Irregular Heart Beats
- Rheumatic Fever
- HIV/AIDS
- Thyroid Disease
- Phlebitis
- Ulcers
- Glaucoma
- Seizures
- Sleep Apnea
- Fainting
- Anemia
- Blood Disorders
- Other
- None
Please describe.
13. Do you have any of the following?*
- Anxiety
- Depression
- Panic Disorder
- Obsessive Compulsive Disorder (OCD)
- Body Dysmorphic Disorder (BDD)
- Hypochondriac
- Other Emotional/Drug/Psychiatric Problems
- None of the above
13. Do you have any of the following?*
- Anxiety
- Depression
- Panic Disorder
- Obsessive Compulsive Disorder (OCD)
- Body Dysmorphic Disorder (BDD)
- Hypochondriac
- Other Emotional/Drug/Psychiatric Problems
- None of the above
14. Have you ever had any of the following?
- Cystic Acne
- Hirsutism (increased body or facial hair)
- Galactorrhea (breast secretions when not pregnant)
- Virilization (appearance of male traits i.e.: deepened voice)
- Infertility
14. Have you ever had any of the following?
- Cystic Acne
- Hirsutism (increased body or facial hair)
- Galactorrhea (breast secretions when not pregnant)
- Virilization (appearance of male traits i.e.: deepened voice)
- Infertility
15. Is it possible that you are pregnant?
- Yes
- No
15. Is it possible that you are pregnant?
- Yes
- No
16. Do you suffer from post-partum hair loss?
- Yes
- No
16. Do you suffer from post-partum hair loss?
- Yes
- No
17. Do you feel that you experience extraordinarily heavy periods?
- Yes
- No
17. Do you feel that you experience extraordinarily heavy periods?
- Yes
- No
18. Have you been diagnosed with PCOS (polycystic ovary syndrome)?
- Yes
- No
18. Have you been diagnosed with PCOS (polycystic ovary syndrome)?
- Yes
- No
19. Which best describes you:
- Not Menopausal
- Perimenopause
- Menopause
- Post Menopause
19. Which best describes you:
- Not Menopausal
- Perimenopause
- Menopause
- Post Menopause
20. Have you had any of the following surgical procedures?
- Hair Transplantation
- Face Lift
- Brow Lift
- Other scalp or facial surgery
20. Have you had any of the following surgical procedures?
- Hair Transplantation
- Face Lift
- Brow Lift
- Other scalp or facial surgery
21. Have you had previous hair restoration surgery, face lifts or brow lifts?
- Yes
- No
21. Have you had previous hair restoration surgery, face lifts or brow lifts?
- Yes
- No
Please provide details including years
22. Have you ever been hospitalized for any other surgery?
- Yes
- No
22. Have you ever been hospitalized for any other surgery?
- Yes
- No
Please list all medical problems and hospitalizations
23. What % of your day do you think about hair?
- <5%
- 5
- 10
- 20
- 30
- 40
- 50
- 60
- 70
- 80
- 90
- 100%
23. What % of your day do you think about hair?
- <5%
- 5
- 10
- 20
- 30
- 40
- 50
- 60
- 70
- 80
- 90
- 100%
24. Do you suffer from any of the following scalp conditions?
- Sensitivity
- Itching
- Tingling
- None of the above
24. Do you suffer from any of the following scalp conditions?
- Sensitivity
- Itching
- Tingling
- None of the above
25. When was the last time you washed your hair?
- Today
- Yesterday
- 2 days ago
- 3 days ago
- More than 3 days ago
25. When was the last time you washed your hair?
- Today
- Yesterday
- 2 days ago
- 3 days ago
- More than 3 days ago
26. What is your height?

Please specify in feet and inches
26. What is your height?
27. What is your weight?

Please specify in lbs.
27. What is your weight?

Please specify in lbs.
28. Are you married?
- Yes
- No
28. Are you married?
- Yes
- No
29. How many children do you have?
29. How many children do you have?
30. Do you consume alcohol?
- Yes
- No
30. Do you consume alcohol?
- Yes
- No
Describe how much alcohol is consumed per day
31. Do you smoke?
- Yes
- No
31. Do you smoke?
- Yes
- No
If Yes, how much?
32. Have you had Lab tests for Hepatitis?
- Yes
- No
32. Have you had Lab tests for Hepatitis?
- Yes
- No
Results:
33. Have you had a recent HIV Test?
- Yes
- No
33. Have you had a recent HIV Test?
- Yes
- No
Results:
34. Have you ever had problems healing?
- Stretched Scars
- Raised or thickened scars
- Keloids
- No known problems with healing
34. Have you ever had problems healing?
- Stretched Scars
- Raised or thickened scars
- Keloids
- No known problems with healing
35. Have you ever been advised to take antibiotics prior to surgery or dental work?
- Yes
- No
35. Have you ever been advised to take antibiotics prior to surgery or dental work?
- Yes
- No
Please specify.
36. Have you ever had excessive bleeding during surgery or at other times?
- Yes
- No
36. Have you ever had excessive bleeding during surgery or at other times?
- Yes
- No
Please specify.
37. Have you ever had a MRSA Infection?
- Yes
- No
37. Have you ever had a MRSA Infection?
- Yes
- No
Please describe.
38. Have you ever had cervical disc or other neck problems?
- Yes
- No
38. Have you ever had cervical disc or other neck problems?
- Yes
- No
Please give details.
What are your hair restoration goals?*
Have you had any hair transplants? Please provide details (i.e., dates and types)*
List relevant health info that might affect a surgical procedure (i.e. keloids, bleeding, diabetes).
Are you currently taking finasteride (Propecia)?*
- Yes
- No
Date you started finasteride (Propecia)*
MM slash DD slash YYYY
Are you currently taking minoxidil (Rogaine)?*
- Yes
- No
Date you started minoxidil (Rogaine)*
MM slash DD slash YYYY
Other medications?
Reasons for Inquiry*
- Cause of Hair Loss
- Robotic Hair Transplant (R-FUE)
- Follicular Unit Transplant (FUT)
- Eyebrow Transplant
- Repair Old Hair Transplant
- Platelet Rich Plasma (PRP)
- Surgical Treatment
- Medical Treatment
Photo Uploads
Instructions for Photos:
1. Submit one different photo for each of the four views (Front, Side/Angle, Top, and Rear)
2. Photos with dry hair only
3. Include your entire head. You may block out your face, but very close-up photos are not useful. The doctor needs to see the overall pattern of your hair loss
4. Click below to upload your photos
5. Once uploaded, you can preview, crop and re-center your photo by clicking on the photo thumbnail
Please check the box below to upload your photos*
- Click Here
Front View*
Select a photo of your frontal hairline.
Click on the photo thumbnail to preview, crop and re-center your photo.
Drop files here or

Max. file size: 15 MB, Max. files: 1.
Side/Angle View*
Select a photo of your hair from the side. Click on the photo thumbnail to preview, crop and re-center your photo.
Drop files here or

Max. file size: 15 MB, Max. files: 1.
Top View*
Select a photo of the top of your scalp. Click on the photo thumbnail to preview, crop and re-center your photo.
Drop files here or

Max. file size: 15 MB, Max. files: 1.
Rear View*
Select a photo of the top of your scalp.
Click on the photo thumbnail to preview, crop and re-center your photo.
Drop files here or

Max. file size: 15 MB, Max. files: 1.

Schedule A Physician Consultation Today

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