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Hair Restoration Consultation with North Valley Plastic Surgery

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Hair Restoration Consultation with North Valley Plastic Surgery WELCOME TO YOUR HAIR RESTORATION CONSULTATION WITH NORTH VALLEY PLASTIC SURGERY Name: _______________________________________________ What is your current hair loss concern? Starting to thin Increased shedding Advanced stage of thinning Missing, damaged or sparse eyebrows Overall thinning Weak or sparse eyelashes Receding hairline Damaged or traumatized eyelashes Bald spot forming in crown Post-Plastic Surgery Hair Loss Little or no hair on top of the scalp Visible Scar Itching or flaking scalp Please check the box which most closely matches your hair loss pattern. Norwood 2 Norwood 2a Norwood 3 Norwood 3a Norwood 3 Vertex Norwood 4 Norwood 4a Norwood 5 Norwood 5a Norwood 6 Ludwig 1 Ludwig 2 Ludwig 3 O Other _______________________________________________________________________________________ If you camouflage your thinning/balding hair, which methods have you used? Wig, toupee or weave Hair extensions Creative hair styling (comb-over, perms) Powder or spray camouflage What is your family's history of hair loss? Mother Father Maternal grandparents Paternal grandparents Brother/sister Don't know Your personal hair restoration objectives (check all that apply): Hairline restoration Increase in frontal density Crown coverage Stop hair loss / decrease shedding Touch-up, refinement or correction of previous procedure Scar Coverage Other (please explain): _________________________________________________________________________________________ Hair restoration solutions of interest: NeoGraft FUE Surgical hair restoration (Follicular-unit Eyelash transplantation extraction: FUE/FOX) Eyebrow transplantation Medical therapy (Propecia, Minoxidil/Rogaine) Beard/moustache transplantation Laser hair therapy (laser hood, laser comb) Body-hair transplantation Nutritional supplementation Scar coverage Post-Plastic Surgery hair transplantation (describe below) Where are you in the hair restoration process? I've started researching my hair restoration options I've had a consultation with another doctor I'm interested in starting non-invasive treatment (Propecia, I'm interested in scheduling a surgical procedure within the Minoxidil /Rogaine, Laser Therapy) next ninety days I've had a hair transplant before I'm interested in scheduling a surgical procedure within the next year How many grafts are you interested in transplanting? I don’t know. Less than 1,000  Less than 2,000  More than 2,000  Patient Comments Do you have any concerns with the hair the hair transplant procedure? Yes____ No____ If yes, what are they? __________________________________________________________________________ North Valley Plastic Surgery Hair Loss Consult Form Estimate of Hair Grafts in Hair Transplant Procedure* *Some patients may require a second treatment to achieve the necessary hair density. Norwood Class Follicular Unit Grafts With Crown** I Under 800 IIa 800-1400 - III 1000-1600 - III Vertex 1200-1600 1600-2200 IIIa 1400-1800 - IV 1600-2200 2200-2600 IVa 1800-2400 - V 2000-2500 2500-2800 Va 2200-2800 - VI 2400-3000 2800-3400 VII 2500-3200 3000-3600 .
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