New Patient Info Form - Hair Restoration printable pdf download

PATIENT INFORMATION:

Date: ____________ Last Name: ________________________________ First Name: __________________________

Home Address: __________________________________________________

____________________________________

City: _____________________ State/Province/Country: _________________ Zip/Postal Code: ___________________

Cell Phone: ________________________ Home Phone: _____________________ Work Phone: __________________

E-Mail Address: ____________________________________________ Date of Birth: ________________ Sex: _______

I prefer to be contacted by (phone/email):______________________

Occupation: ____________________________

Emergency Contact Name: _______________________________ Emergency Contact Phone #: ____________________

*How did you first hear about Dr. Anderson? (Please chose from the options below)

-Referral: (Doctor/Friend/Relative/Patient) ______________________________________________________________

-Internet: (Google/YouTube/Facebook/Other) *Please list search terms/keywords used __________________________

-Magazine: (BestSelf, Atlanta Magazine, Living InTown, Other) ______________________________________________

-Health Club: (Lifetime Fitness, LA Fitness) _______________________________________________________________

-Clubs: (Country/Golf) _______________________________________________________________________________

Have you visited our web site? ____________ How much do you know about hair restoration? ____________________

_________________________________________________________________________________________________

When did your hair loss begin? ______________ Family History of baldness (Mom’s/Dad’s side)? __________________

Have you ever worn any of the following for an extended period of time? (Hairpiece, Wig, Pony Tail, Weave, Braids,

Dreadlocks, Corn Rows) _______________________________________________ Approx # of years worn: __________

What, if any, concerns do you have about hair restoration? _________________________________________________

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New Patient Info Form - Hair Restoration