Online Consultation

What is your current state of hair loss?
Starting to thin
Advanced stage of thinning
Overall thinning
Receding hairline
Bald spot forming in crown
Little or no hair on top of the scalp

Please check the box which most closely matches your hair loss pattern:
Norwood 2 Norwood 2a Norwood 3 Norwood 3a Norwood 3 Vertex
Norwood 4 Norwood 4a Norwood 5 Norwood 5a Norwood 6
Ludwig 1 Ludwig 2 Ludwig 3
What therapies have you tried?
Past
Currently
Propecia
Rogaine (minoxidil)
Saw palmetto/ other herbs, supplements
Hair Transplantation
Laser therapy
*name:
*E-mail Address
*Home Phone:
*Cell Phone:
*Age:
Gender:

What is your family's history of hair loss?
Mother
Father
Maternal Grandparents
Paternal Grandparents
Brother/Sister
Don't Know

Your personal hair restoration objectives (check all that apply):
hair Restoration
Increase in Frontal Density
Crown Coverage
Stop Hair Loss / Decrease Shedding
Touch-up refinement or correction of previous procedure
Scar Coverage
Other (please explain)

Required Fields marked with *

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1825 SE Tiffany Ave., Port Saint Lucie, FL 34952. 772-528-2916 TCHRhair@bellsouth.net