1Personal Details2Transplant Details3Photo Upload Name* First Last Phone*Email* Age*Please Select...Under 1616171819202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364656667686970717273747576777879808182838485Over 85Height* Weight Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How did you hear about Hasson and Wong?*Please SelectPatient ReferralSocial Media (Facebook, Twitter, YouTube etc..)Internet Search (Google, Yahoo etc..)Internet ForumsDirectory (Yellow pages, White Pages etc..)RadioTelevisionConsultant: DougConsultant: Mike – SeattleConsultant: Thomas – OsloConsultant: James – TorontoConsultant: LorenzoConsultant: Marco – ItalyConsultant: Marco – SpainOther Referral Preferred Method of Extraction*Open to methods recommended by the doctorPrefer FUT but open to FUEPrefer FUE but open to FUTPrefer FUT onlyPrefer FUE onlyInterested in a combination of both methods if necessary to maximize the number of graftsHave you had hair transplant surgery before?* Yes No Previous Surgery Details*Please enter information for each of your past surgeries including: - Name of Doctor - Year of Surgery - Type of Surgery - Number of Grafts.Have you used Propecia / Proscar / Finasteride?* Never Used Stopped using more than 2 months ago Stopped using less than 2 months ago due to side effects Stopped using within last 2 months Currently using, but not consistently Currently using as frequently as prescribed Using another medication such as Dutasteride Please elaborate below in your hair loss story.Please indicate medication type and dose below in your hair loss story.Are you using* Name brand Propecia from Merck, 1 mg per day Name brand Proscar from Merck, one 5mg tablet cut into quarters, 1/4 tab per day Name brand Propecia or Proscar, if taking another dose other than above, please indicate in your hair loss story below Generic Finasteride, 1 mg per day None of the above, please indicate medication and dose in your hair loss story below Have you used Rogaine / Regaine / Minoxidil?* Never Used Stopped using more than 2 months ago Stopped using less than 2 months ago due to side effects Stopped using within last 2 months Currently using, but not consistently Currently using as frequently as prescribed Approximate date you would like to have your procedure?*Please Select...Within the next 1-4 weeks if possible1-3 months3-6 monthsLater than 6 monthsTell us your hair loss story:*Describe your restoration goals:* Upload Photo Instructions Ensure the room is evenly lit and bright. This is best accomplished in the daytime using natural light. Do not use a flash. It obscures the scalp. If you think you need a flash, you need a brighter room. Please note the following: Maximum file size: 5 MB per image, images must measure less than 3200px x 3200px.FRONT Photo* Drop files here or Select files Max. file size: 10 MB, Max. files: 1. BACK Photo* Drop files here or Select files Max. file size: 10 MB, Max. files: 1. Side Photo* Drop files here or Select files Max. file size: 10 MB, Max. files: 1. TOP/CROWN Photo* Drop files here or Select files Max. file size: 10 MB, Max. files: 1. Upload Additional Photo'sIf you would like to upload additional photo's, please use this section. Drop files here or Select files Max. file size: 10 MB, Max. files: 5. Submit your photo's*By clicking "I agree" you are allowing Hasson & Wong to provide an accurate estimate about your case, based on the photo's you provide. Your Photo's will be private and secure and will not be used without your permission. I agree Free Consultation Application was last modified: June 28th, 2021 by Hasson & Wong
