PHONE: 1 (800) 510-3386

Please fill out this form to learn more about treating your hair loss and your options with hair transplants or alternative treatments. You can also submit to us your hair loss photos which will give us a better understanding of your hair loss and an approximate idea of your hair replacement needs. One of our doctors will review your photos and provide you with an evaluation and recommendation.

Your information and photos become a part of your medical file at HRC and we will not sell, trade, lease or give that information to anyone – ever. If you have more questions, comments or helpful information to give us after you have completed this form, please do not hesitate to contact us again. An asterisk (*) indicates a required field.

    • First Name:

    • Last Name:

    • Address:

    • City:

    • State/Province:

    • Zip Postal Code:

    • Phone:

    • Best time to call:

    • Email*:

    • Personal / Health Information

    • Age:

    • Gender:

      MaleFemale

    • Please list any existing medical conditions or allergies:

    • *Any family history of baldness or thinning hair?

    • *Did baldness or thinning hair come about rather suddenly?(required)

    • *What is your time frame to proceed?

    • Will you require financial assistance?(required)

    • Please include any additional information, concerns or questions that will help us to better fulfil your request

    • Photo Submission

    • Please follow the guidelines listed below when submitting your photographs. This will allow your virtual consultation to be as close as possible to an in-person consultation.

    • When taking your photographs:

      • Do not use a flash. Instead, take the photographs in a room with bright, natural lighting.

      • Have the photographs taken from a distance of 3 - 5 feet.

      • Keep the target in focus and centered in the frame.

    • When submitting your photographs:

      • Use digital photos or print photos that have been scanned.

      • Use jpg or jpeg file types.

      • Do not exceed 4MB (4,000kb) per photograph. Larger photographs must be resized.

    • Provide photos showing the following angles:

    • Front hairline
      We need to be able to understand how your existing or new hairline frames your face. This is imperative for the review process. If possible, take some time to draw your hairline on your scalp to show us where you would like to have it placed. This helps us to understand your desires and expectations from the procedure.
      Upload Photo

    • The top of your scalp
      This gives us an overall view of your hair loss situation. The top view is important as it helps us determine the extent of existing hair loss and possible future hair loss
      Upload Photo

    • Oblique profile
      The profile is very important in assessing the needs of our patients. The profile helps us understand the extent of hair loss.
      Upload Photo

    • The back of the scalp
      If possible, include a photograph with your donor hair pulled up either with your hand or with a comb. This helps us determine your donor density.
      Upload Photo