Personal Information Full Name: Date of Birth: Gender: MaleFemale Address: City/State/ZIP: Phone Number: Email Address: Occupation: Medical History A. General Health Questions Do you have any chronic medical conditions? YesNo If yes, please specify: Are you currently taking any medications? YesNo If yes, list them: Do you have any allergies? YesNo If yes, please specify: Do you smoke? YesNo Do you consume alcohol? YesNo Do you have a history of excessive bleeding or blood clotting disorders? YesNo Have you had any previous surgeries? YesNo If yes, please specify: Do you have HIV or Hepatitis? YesNo If yes, please specify: Do you have a heart problem or have you had a heart operation before? YesNo B. Hair Loss History When did you first notice hair loss? Is there a family history of hair loss? YesNo Have you previously tried any hair loss treatments? YesNo If yes, which ones? Have you undergone a previous hair transplant? YesNo If yes, when and where? Do you have any scalp conditions? YesNo What are your goals/expectations for the hair transplant? Hair Transplant Procedure Information Preferred Hair Transplant Technique (if known): FUE (Follicular Unit Extraction)DHI (Direct Hair Implantation)Not Sure, Need Consultation Have you consulted with a doctor about your suitability for a hair transplant? YesNo Do you have any concerns or specific questions about the procedure? Upload Your Photo: Consent & Acknowledgment A. Procedure Consent I acknowledge that I have provided accurate medical history information and understand the risks, benefits, and expected outcomes of hair transplantation. I Agree Patient Signature: Date: B. Photo & Data Consent (Optional) Do you consent to pre- and post-procedure photos for medical records? YesNo Do you consent to your photos being used for educational or promotional purposes (with identity protection)? YesNo
