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Online Hair Loss Consultation form

Thank you for visiting our website. Many of our patients visit us for Hair Restoration and many other cosmetic surgical procedures from accross the country and around the world. In order to better serve you and address individual concerns we have created this online consultation form which allows you to communicate directly with Dr. Wasserbauer.

Please fill out the form below completely and a patient coordinator will reply with Dr. Wasserbauer's evaluation and suggestions. For a personal consultation call toll free - 1-877-8-HAIRMD

(This form is not intended to replace a physical exam and personal consultation with a physician.)

 
Male and Female Hair Loss Classifications
Male and Female Hair Loss Classifications

 
First Name*:
Last Name*:
Street
City
State
Zip Code
General health*:
Current Age:
Age when hair loss began:
Select Hair Loss Pattern from chart above.
 
Male Hair Loss Classification:
Female Hair Loss Type:
Past or present Hair loss treatments:
List any medical conditions:
List any medications required:
Family History of baldness
Please indicate if any of your following relatives have suffered mild, moderate or severe hair loss.
 
Father*
Paternal Grandfather*
Mother*
Maternal Grandfather*
Paternal Uncles*
Maternal Uncles*
Night time phone*
Daytime Phone*
E-mail*
How would you like to be contacted?
Special Concerns or comments
To help us avoid computer generated inquiries and spam, please enter the letters and numbers exactly as you see them in the box below.
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