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All questions contained in this questionnaire are strictly confidential.

First Name *

Last Name *

Email *

Phone *

Street Address *

City *

Postal code *

State *

Do you have a family history of Alopecia or hair thinning? (if yes, explain) *

When did you last have a normal head of hair? *

Was onset of hair loss sudden or gradual? *

Is your hair coming out “by the roots” or is it breaking off? *

Do you feel that your scalp hair is slowly thinning out over the top without losing excessive numbers of hairs daily? *

Yes

No

PATIENT CONSENT & PAYMENT

I have received information on the risks and benefits of the hair loss screening and the treatment options recommended to me. I fully understand this information and have had the opportunity to ask any questions.

I consent to undergoing the hair loss screening and, if appropriate, to receiving treatment as recommended by my healthcare provider. I understand that I may withdraw my consent at any time by informing my provider.

Signature:

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