(303) 744-1202f
Fax: (303) 744-0418
Questionnaire

Name:
Street Address:
Email Address:
City: State: Zip:
Preferred Phone: Type: Home Work Cell
Age: Sex: Male Female Married Divorced Widowed Single

DESCRIBE YOUR HAIR AND HAIR LOSS-
Hair is: Straight Wavy Wiry Curly
Coarseness: Fine Medium Fine Medium Medium Coarse Coarse

Click Here For Previous Treatment
Rogaine: Using Now? Yes No
Propecia: Using Now? Yes No
Hairpieces: Using Now? Yes No
Transplants? Yes No
      Number of Sessions One Two Three Four Greater Than Five
      Average Number of Grafts/Session: Zero to 500 501 to 1000 Greater Than 1000
Scalp Reductions? Yes No
      Number of Scalp Reductions One Two Three Greater Than Three

Clicking on the photos that best resemble your hairloss pattern will tell you the approximate number of grafting sessions required for each of 3 zones. If you have no hair loss in one or two of the zones, do not click on any photo in that particular zone.

To obtain a virtual consultation:
(1) Click on the photos that best resemble your hair loss
(2) Click on the hair loss pattern that most resembles yours.

MALES
Degree of Thinning(Male): Click on photo that best resembles your hair loss
Hairline
Early Thinning
Moderately Thin
More than Halfway Bald
Nearly Totally Bald
Front of Scalp
Early Thinning
Moderately Thin
More than Halfway Bald
Nearly Totally Bald
Top of Scalp
Early Thinning
Moderately Thin
More than Halfway Bald
Nearly Totally Bald

Hamilton Scale (Men):
Click on Diagram
That Best Applies
Clicking on the diagram that best resembles your hair loss pattern will tell you the approximate number of required grafts or each of the 3 zones: hairline, front of scalp, and crown of scalp
 

Estimated # of Grafts Per Session for: Estimated # of Sessions Necessary for:
A. Hairlines A. Hairlines
B. Anterior Scalp B. Front of Scalp
C. Crown of Scalp C. Top of Scalp
Total # of Grafts (Range)

FEMALES
Click on zones of hair loss on your scalp
Patterns of Female Hairloss:
Crown
Central
Frontal
Ludwig I
Ludwig II
Ludwig III
Area of Hairloss:
Early Thinning
Moderately Thin
Very Thin
Nearly Bald

Estimated # of Grafts Per Session for: Estimated # of Sessions Necessary:
A. Hairlines
B. Anterior Scalp
C. Crown of Scalp
Total # of Grafts (Range)

REPAIR
Do you need hair transplant repair (repair of previous results)? YES NO
Have you had? Plugs Minigrafts Scars Poor Graft Growth Unsightly Grafts Other
Donor Area Repair? Donor Scar Width: 1/8'' 1/4'' 3/8'' 1/2'' or Larger
Scar Fill-in? Location Approximate Scar Size: inches x inches
    Or cm x cm

Could you come to Colorado for your Surgery Yes No

Which days would you be available for your surgery?
Monday Tuesday Wednesday Thursday Friday

Which months would you be available for surgery?
January February March April May June
July August September October November December

I want a chain clinic (only as good as the surgeon present that day - ask to meet the surgeon during a consultation before you fly in for a session)
I want a discount clinic (you get what you pay for)
I want a surgeon on a paid website "referral list" (these are often selected only by the ability to pay to be listed on the site)
I want the best. Click to see before and after photos of our actual patients

Call (303)744-1202 for your price

For questions or further information, call (303) 744-1202
Would you like to mail photos to us for a free professional opinion letter? Send to:
Hair Transplant Clinic of Colorado
950 East Harvard Avenue, Suite 630
Denver, Colorado 80210

If you click below, your personal information and questionnaire will be transmited to the Colorado Dermatology Center(by doing so, you give permission for us to contact you and release your right to privacy in this regard.)