Colorado Dermatology Center

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

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

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.)