At Legacy Hair Restoration, we value what you have to say and strive to establish an honest and straightforward dialog with you regarding your important decision-making process. Please complete the information below and click the "Submit" button, and one of our Consultants will contact you within 24 hours.

Name*
Street Address*
City*
State*
Zip *
Telephone*
Email*
I prefer to be contacted by:	email phone either
Preferred time for Online Virtual Consultation:	AM PM

Hairloss Evaluation
1.	Age:            Gender:  Male Female
2.	What color is your hair?
	Black      Medium Brown      Light Brown Gray Blonde Red
3.	Which characteristic best describes your natural hair?
	Straight      Curly      Wavy
4.	What is the texture of your hair?
	Fine      Medium      Thick
5.	Select the image that best describes your hairloss condition when your hair is wet.
6.	At what age did you first notice your hairloss?
	< 20      41-50 21-30      50+ 31-40
7.	Has your hairloss or thinning increased significantly in the past five years?
	Yes      No
8.	Is your hairline receding at the temples?
	Yes      No
9.	Are you developing a bald spot that's visible from behind?
	Yes      No
10.	Are you experiencing hairloss on the top of your head?
	Yes      No
11.	Are you able to see a lot of skin through your hair when your hair is dry?
	Yes      No
	When your hair is wet?
	Yes      No
12.	Are you able to see a well-defined horseshoe shaped pattern of baldness on your head when your hair is dry?
	Yes      No
	When your hair is wet?
	Yes      No
13.	Is the texture of the hair on top of your head finer or frizzier than the hair on the sides and back of your head?
	Yes      No
14.	Have you noticed that the hair on the sides and back of your head needs to be cut more frequently than the hair on the top of your head?
	Yes      No
15.	What would you like to achieve with hair transplantation (restore the front hairline, mid scalp, back, or your entire balding area)?
16.	Have you consulted with a doctor about your hairloss condition?
	Yes      No
	If so, with whom?
17.	What treatment, if any, was recommended?
18.	Have you ever had surgical hair restoration performed?
	Yes      No
	If so, with whom?
19.	Have you treated your hairloss with any of the following?
	Rogaine Past      Present Saw Palmetto      Past Present Propecia Past Present Anacor Past Present Other Past Present
20.	Please rank the concerns that apply to your feelings about hair restoration surgery in order of importance to you (1 = your greatest concern).
	Camouflaging after surgery Affordability Discomfort Final result Time off work Other

Medical Information

1.	How is your general health?
	Good      Fair Poor
2.	Are you on any medications?
	Yes      No If yes, please list
3.	Are you taking any blood thinners?
	Yes      No
4.	Do you have high blood pressure?
	Yes      No
5.	Do you have diabetes?
	Yes      No
6.	Do you have glaucoma?
	Yes      No
7.	Do you have scalp disease?
	Yes      No
8.	Is there a family history of hair loss?
	Yes      No

* How were you referred to Legacy Hair Restoration	Salon Professional Pharmacist Medical Journal Article Newspaper Ad Search Engine Personal Friend or Family Other
If Other:
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