Hair Survey

Home . Hair Survey

Complete the hair consultation survey below to help Dr. Wise understand your hair loss concerns and determine the best treatment options for you.

Hair Restoration Consultation Survey

Please fill out the consultation form below. Dr. Wise and his team will review your information and contact you to schedule a personalized consultation.

1. Your Information

First Name(Required)

Last Name(Required)

Phone(Required)

Email(Required)

Date of Birth(Required)

What is your occupation?(Required)

Street Address(Required)

Address Line 2

City(Required)

State(Required)

Zip(Required)

2. Hair / Health Profile

When did you first notice you were losing hair?

Have you ever used Rogaine?

Have you ever been prescribed and used Propecia?

For how long?

Any side effects?

Do you take any medications?

Do you have any existing medical conditions or illnesses?

Do you smoke?

Have you had a hair transplant in the past?

Tell us about hair loss on your mother's side of your family.

Tell us about hair loss on your father's side of your family.

Tell us about any hair loss experienced by your brothers or sisters.

3. Your Hair Transplant

What do you hope to achieve with hair restoration, and what technique are you interested in?

FUE

Strip technique (FUT)

PRP Treatment

Facial Hair Restoration

Not Sure

Select the areas of your scalp where you need hair restoration

Front

Top

Small Crown

Expanded Crown

Have you met with other hair transplant doctors?

What treatment was recommended?

When are you thinking of scheduling your hair restoration procedure?

How did you hear about the Wise Institute for Hair Restoration?

Add your comments!

4. Upload your photos

Front Photo

Choose FileNo file chosen

Top Photo

Choose FileNo file chosen

Left Photo

Choose FileNo file chosen

Right Photo

Choose FileNo file chosen

Back Photo

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Front Photo(Required)

Accepted file types: jpg, jpeg, png, gif, Max. file size: 220 MB.

Top Photo(Required)

Accepted file types: jpg, jpeg, png, gif, Max. file size: 220 MB.

Left Photo(Required)

Accepted file types: jpg, jpeg, png, gif, Max. file size: 220 MB.

Right Photo(Required)

Accepted file types: jpg, jpeg, png, gif, Max. file size: 220 MB.