Welcome to your virtual consultation with Dr. Moore: Please read each of the following questions and indicate your answers. Once you complete this confidential patient form, click send to forward your information to Dr. Moore.
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Please check the box which most closely matches your hair loss pattern.
Other (describe)
What therapies have you tried?
Your personal hair restoration goals (check all that apply): Hairline 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):
What is your timeline in the hair restoration process? I've started researching my hair restoration options I'm interested in starting non-invasive treatment (Propecia, Minoxidil /Rogaine, Laser Therapy) I've had a hair transplant before I've had a consultation with another doctor I'm interested in scheduling a surgical procedure within the next ninety days I'm interested in scheduling a surgical procedure within the next year
What is your primary concern or question at this point? ( add any additional comments below)
How did you hear about this website? Friend (Who?) Hair loss website: Other magazine or newspaper article Other TV news Search engine: Other
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