2940 N Swan Rd, Suite 130, Tucson AZ 85712

CONGRATULATIONS! YOU ARE ONE STEP CLOSER TO RESTORING YOUR HAIR

Let’s Get to Know Your Hair Loss Situation a Bit Better

This short survey helps our team evaluate your candidacy and recommend the best treatment plan—completely personalized to you. Please answer these questions to the best of your ability.

How long have you been experiencing hair loss? *

Less than 1 year

1-3 years

3-5 years

5+ years

What areas are you currently experiencing hair loss? (Select all that apply) *

Receding hairline

Crown (top/back of head)

Mid-scalp / Top

Temples

Overall thinning

Patchy spots

Other (please describe)

How would you describe the current state of your hair loss? *

Mild

Moderate

Severe

Have you ever had a hair transplant before? *

Yes - FUE method

Yes - FUT (strip) method

Yes - but I’m not sure which method was used

When and where did you have it? *

Are you currently using any hair loss treatments? (Check all that apply) *

Minoxidil (Rogaine)

Finasteride (Propecia)

PRP Therapy

Laser therapy

Hair vitamins

None

What is your goal with hair restoration? *

I want to stop further hair loss

I want to restore my hairline

I want a full transformation

I'm not sure yet

When are you hoping to have the procedure done? *

Within the next 30 days

In the next 2–3 months

3–6 months

Just researching for now

Are you ready to invest in a solution if you're a good candidate? *

Yes, I’m ready now

Possibly, depending on the options

Not sure

Do you have any medical conditions that might affect surgery? *

Yes (please specify)

Please specify if you have any medication conditions that might affect surgery. *

How did you hear about Miami Hair Institute? *

Google Search

Instagram/Facebook

Referred by a friend or doctor (please tell us who).

Other

Who referred you to Miami Hair Institute? *

What is your age? *

Phone *

Please enter your email *

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CONTACT

We welcome your inquiries. You can reach us via phone, fax or email.

Toll Free: (800) 840-9761

Phone: 520-290-5555

Email: [email protected]

Please address your written correspondence to: Physician's Hair Institute 2940 N Swan Rd, Suite 130, Tucson AZ 85712