Free Online Hair Loss Consultation

Surgical Photo Assessment Form

How Would You Like To Be Contacted?*

Email
Phone

Hair Loss Info

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)*

Are you currently taking minoxidil (Rogaine)?*

Yes
No

Date you started minoxidil (Rogaine)*

Other medications?

Photo Uploads

Instructions for Photos:

Submit one different photo for each of the four views (Front, Side/Angle, Top, and Rear)
Photos with dry hair only
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
Click below to upload your photos

*

Click Here

Front View*

Select a photo of your frontal hairline

Side/Angle View*

Select a photo of your hair from the side

Top View*

Select a photo of the top of your scalp

Rear View*

Select a photo of the back of your scalp

Reasons for Inquiry

You may select more than one option:

Personal Information

First Name*

Last Name*

Email Address*

Enter Email Confirm Email

Phone Number

Location*

City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Gender*

Current Patient of Bernstein Medical?*

General

How Did You First Hear About Bernstein Medical?*

Search Keyword

Are They a Patient at Bernstein Medical?

Yes
No

Name of Family Member or Friend

Stylist or Salon Name

Magazine Name

Physician Name

Other Referral?

Comments

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Surgical Photo Assessment