New Patient Info Form - Hair Restoration Page 2

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Please explain your hair restoration goals and expectations: (i.e. FUE, STRIP, PRP, Preventative Therapy, what areas of loss
to address)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
MEDICAL HISTORY
Date: ____________
Last Name: _________________________________ First Name: _________________________
*PLEASE ANSWER THE FOLLOWING QUESTIONS AS COMPLETE AS POSSIBLE*
(Please provide details where appropriate. If any aspect of your health changes, please let us know.)
How is your health in general? ________________________________________________________________________
Drug Allergies? Please list: ___________________________________________________________________________
Allergies to Latex or Collagen products? _________________________________________________________________
List ALL current prescription medications, non-prescription medications, vitamins, and supplements you are currently
taking, including doses:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Have you ever had Hepatitis, Diabetes, Glaucoma, High Blood Pressure, Heart Disease, Pace Maker, Irregular Heart
Beats, Bleeding Disorders, Thyroid Disease? _____________________________________________________________
_________________________________________________________________________________________________
Skin/Scalp Conditions? ______________________________________________________________________________
Have you ever had problems healing? __________________________________________________________________
History of scarring, Keloid? ___________________________________________________________________________
Please list ALL operations/hospitalizations with dates (including hair transplants, scalp reductions, hair systems etc.):
_________________________________________________________________________________________________
_________________________________________________________________________________________________
*This is my authorization for examination and testing necessary to make a medical diagnosis. AHSC requires a 24-hour notice of
cancellation. No call/no show appointments are subject to a $150.00 fee that will be billed to the patient. We thank you for
your understanding and cooperation. I acknowledge that the information given has been completed by the patient or a
representative of the patient.
Signature_________________________________________________________ Date____________________________

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