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Thank you for your interest in Van Scoy Hair Clinics. Please note that we will not sell or redistribute any information you supply. Information gathered here is strictly confidential and is used for our internal evaluation only. * means it's a mandatory field.

 
Personal Info
 
Name:*  
Address:  
City:  
State:     Zip:
Phone:*  
E-mail:*  
 
Consultation Info
 
Hair color:   Brunette Blonde Black Grey Red
 
Scalp condition   Normal Combination Oily Dry
 
Texture   Coarse Fine Curly
 
 
Where are you on the Norwood hair loss classifications chart?
 
Norwood Level 2
Level 2
Norwood Level 3
Level 3
Norwood Level 4
Level 4
Norwood Level 5
Level 5
Norwood Level 6
Level 6
Norwood Level 7
Level 7
 
 
When did you first begin losing your hair?   1-12 months ago 2-4 years ago 4-8 years ago
8-16 years ago 16-32 years ago 32 + years ago
 
After shampooing, how long for your hair to get oily?   1 to 3 days 4 to 5 days 6 days or longer
 
Hair loss hereditary in your family?   Father Mother Brothers-sisters
No heredity involved Unknown
 
How much hair do you lose per day?   0-20 21-40 41-60 60 or more
 
In what age group are you?   Less than 20 years 21 to 30 31 to 40 41 to 50 51 to 60 61 to 70 70 and older
 
Factors unrelated to androgenetic problems:
(Check all that apply)
  Have you changed medication recently?
Do you suffer from anemia?
Have you given birth in the last 4 months?
Changed contraceptive medication in past 6 mos.?
Do you suffer from any thyroid afflictions?
Have you been given anesthesia in the last 5 months?
Are you currently on a reducing diet?
Have you suffered from fever in the last 6 months?
 
How did you hear about Vanscoy Hair Clinic:   TV
Newspaper
Yellow Pages
Radio
Referral
Internet
Other
 
If *Other*, explain:  
 
Comments & Concerns:  
 
   
 
 
608 Claremont Avenue
Ashland, Ohio 44805
Phone:(419) 289-6665
Fax:(419) 281-4351
1-800-332-6341
5592 Broadview Rd
Cleveland, Ohio 44134
Phone:(216) 739-2290
Fax:(216) 739-2280
1-800-863-6341
90 Northwoods Blvd
Columbus, Ohio 43235
Phone:(614) 885-6090
Fax:(614) 885-1560
1-800-707-6341
 

 


Van Scoy Hair Clinics a member of Transitions International Group, an elite group of Hair Restoration Specialists, comprised of an award-winning international membership of the world's finest hair replacement and hair restoration clinics.

Whether you are just beginning to experience some hair loss or are in most advanced stages of natural or medically-related hair loss, we can help with our full spectrum programs of male and female hair loss treatments and solutions.


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