Hair Loss Consultation Consent Form
Complete this form before your hair loss consultation so the provider can review your concerns, health history, and consent to proceed.
Patient Information
Full Name
*
First Name
Middle Name
Last Name
Preferred Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sex / Gender
Please Select
Male
Female
Non-binary
Prefer to self-describe
Prefer not to say
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
*
Phone
Email
Text Message
Prefer not to say
Hair Loss Details
Primary concern
*
Shedding
Thinning
Receding hairline
Patchy loss
Scalp irritation
Other
When did the hair loss start?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How long has this been happening?
*
Please Select
Less than 1 month
1–3 months
3–6 months
6–12 months
More than 1 year
Areas affected
*
Front hairline
Crown
Top of scalp
Temples
All over
Eyebrows
Beard
Other
Is the hair loss getting worse?
*
Yes
No
Not sure
Known triggers or changes
Stress
Recent illness
Medication change
Diet change
Postpartum
Recent surgery
Hormonal change
New hair products
Other
Additional details
Medical History and Current Care
Current medications
Supplements or vitamins
Previous hair loss treatments
Known allergies
Relevant medical conditions
Thyroid condition
Autoimmune condition
Hormonal condition
Anemia or iron deficiency
Scalp condition
Other
Family history of hair loss
Pregnancy or breastfeeding status
Not applicable
Pregnant
Breastfeeding
Possibly pregnant
Prefer not to say
Recent procedures or significant health changes
Consultation Preferences
Preferred consultation date and time
Consultation type
*
In-person
Virtual
No preference
Preferred provider
Please Select
Any available provider
Dr. A. Smith
Dr. J. Lee
Dr. M. Patel
Other
Best time to contact you
Hour Minutes
AM
PM
AM/PM Option
What would you like to discuss?
*
Evaluation only
Treatment options only
Both evaluation and treatment options
Consent and Acknowledgment
Consent Declaration
Signature
Submit
Submit
Should be Empty: