Hair Transplants, Hair Replacement and Medical Hair Restoration

Site Map

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?

Level 2

Level 3

Level 4

Level 5

Level 6

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.

This site designed and maintained by Web-Max.com, E-mail Webmasters

� 1996-2005 Van Scoy Hair Clinics