1. Your Information
2. Hair/Health Profile
3. Your Hair Transplant
4. Upload Your Photos

If you are a human, do not fill in this field.

1. Your Information

First Name

Last Name

Phone

Date of Birth

What is your occupation?

Street Address

Address Line 2

City

State

Zip

2. Hair / Health Profile

When did you first notice you were losing hair?

Have you ever used Rogaine?

Have you ever been prescribed and used Propecia?

For how long? Any side effects?

Do you take any medications?

Do you have any existing medical conditions or illnesses?

Do you smoke?

Have you had a hair transplant in the past?

Tell us about hair loss on your mother's side of your family.

Tell us about hair loss on your father's side of your family.

Tell us about any hair loss experienced by your brothers or sisters.

3. Your Hair Transplant

What do you hope to achieve with hair restoration, and what technique are you interested in?

FUE

FUT (Strip technique)

PRP treatment

Facial Hair Restoration

Not Sure

Select the areas of your scalp where you need hair restoration

Front

Top

Small Crown

Expanded Crown

Have you met with other hair transplant doctors?

When are you considering undergoing hair restoration treatment?

When are you thinking of scheduling your hair restoration procedure?

How did you hear about the Wise Institute for Hair Restoration?

Add your comments!

4. Upload your photos

Example

Front Photo

Example

Top Photo

Example

Left Photo

Example

Right Photo

Example

Back Photo

Schedule a Consultation

973-658-4314

1680 Route 23, Suite 120, Wayne, NJ 07470

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Hair Survey

1. Your Information

2. Hair / Health Profile

3. Your Hair Transplant

4. Upload your photos

Schedule a Consultation