Thank you for your interest in a hair restoration consultation with Dr. Verret, facial plastic surgeon in the North Dallas suburb of Plano, TX. Please read and answer each of the questions as this will give Dr. Verret a better idea of how to assist you in your search for a more youthful head of hair. When you are done, please click submit and your answers will be forwarded to Dr. Verret. Realize that while we make every effort to maintain the confidentiality of internet communications there is a small risk of others obtaining this information. If you would prefer, you may print and fax this questionnaire to Dr. Verret at 972.473.7828

Your Name:
Your E-mail:
Age:
Gender: Male Female

Does anyone in your family suffer from hair loss? (Check all that apply)
Mother
Father
Maternal grandparent(s)
Paternal grandparent(s)
Brother(s)/Sister(s)
Not Sure

What part of your hair bothers you?
Starting to thin
Significant Hair Loss
Receding Hair Line
Bald Spot on back of scalp
Eyebrow loss
Eyelashes
Hair Loss after Plastic Surgery
Hair Loss after an Accident or Trauma

Please check the box that most closely matches your hair.

Hair Diagnosis History

I have been evaluated by a physician for my hair loss.	Yes	No
I have a diagnosed medical cause for hair loss.	Yes	No

If yes, please describe your condition:

What treatments have you received?

What are your goals for hair restoration? (Check all that apply)
Restore a natural hairline
Increase hair density
Cover balding crown
Stop hair loss / maintain current coverage
Correct previous procedure
Scar coverage
Improve previous results

Please select the procedure(s) you are interested in pursuing?
Surgical Hair Restoration
Medical therapy (Propecia/Rogaine)
Nutritional/Alternative Treatments
Post plastic surgery hair restoration
Eyelash transplant
Eyebrow transplant
Beard/mustache transplant
Scar coverage
Hair plug correction

Where are you in the process? (check all that apply)
I'm in the early research phases of my options.
I have already had a consultation with a physician.
I've had a hair transplant before.
I wish to explore all non-surgical options.
I wish to schedule a full online consultation with Dr. Verret.
I wish to schedule an in person consult with Dr. Verret.
I wish to schedule a hair transplant as soon as possible.
I wish to schedule a transplant in the next 6 months.

While we attempt our best to maintain the confidentiality of online communications, please realize that these communications are not completely secure. By pressing submit, you understand this. If you wish, you may print out this form and fax it to Dr. Verret at his office fax 972.473.7828.