Contact

1020 North Palafox St.
Pensacola, Florida 32501
850.308.1738
ONLINE HAIR TRANSPLANT CONSULTATION FORM

To get started right away please answer the questions below for our physicians to evaluate if you are a candidate for hair loss therapy.
* indicates a required field

First, we will require a history on your hair loss ...

a

During the past year how has your hair loss progressed, if at all?*
Have you previously had a hair transplant?*
How long have you been experiencing hair loss?*
Tell us your story.*
e.g. Briefly describe your experience in hair loss and any treatments you may have undergone.
Have members of your immediate or extended family, male or female, experienced hair loss?
Check all of your family members if any apply.
 Mother Father Maternal Grandfather Maternal Grandmother Paternal Grandfather Paternal Grandmother Daughter Son Sister Brother Maternal Aunt Maternal Uncle Paternal Aunt Paternal Uncle Maternal Cousin Paternal Cousin
Select which of the following treatment options, if any, you have undergone.  Rogaine or Regaine (Minoxidil) Propecia or Proscar (Finasteride) Light therapy
Are there any other hair loss treatments you have undergone?
Are you currently being treated?
If yes, for how long?
What are your Goals for hair restoration?*
e.g. What do hope you to acheive?
What is the Approximate date you would like to have your procedure?

 

We need to know a little more bit about you...

Name*
Age*
Email*
Phone Number*
Street Address*
City*
State*
Zip Code*
How did you hear about us?


To complete your online assessment we require a few photos so our hair transplant physicians can properly assess you.


Please Note: We will be unable to properly provide an assessment if we recieve photos of poor quality or fail to show the views as requested below.
Each image must be no more than 1MB per photo. An ideal image size for assessment would be either 1024 x 768 or 800 x 600, ratio: 1.33.
The photo uploader requires that you send only JPG format images.

Photo Top:
Photo Front:
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Photo Left:
Please make sure you have completed all the required fields and hit send.
1020 North Palafox St.
Pensacola, Florida 32501
+850.308.1738