Hair Transplant Consultation Form

For an online consultation, please complete the consultation form below and attach photos. Please read and follow the photo guidelines prior to submitting the form. A consultation is only possible if the required photos are submitted.

Photo Upload Restrictions
Photos must not exceed 4MB (4,000kb) each. Please resize photos that exceed this limit. Acceptable photo file types are jpg or jpeg.

Step 1: Submit your contact information (* indicates required fields)
* Name
* Age
* Email
* Phone
* Address
* City
* Prov/State
* Zip/Postal
* How did you find Hasson & Wong?	Other:
* Brief hair loss history
Have you had a hair transplant procedure? If "Yes", please provide details: date(s) of procedure, number of grafts, how many sessions, which clinic, etc.
Are you taking Propecia? If "Yes", for how long?
Are you taking Rogaine? If "Yes", for how long?
* Expectations from procedure
*Approximate date you would prefer to have your procedure?
Preferred method of contact
Would you like to receive our e-newsletter?	Yes No
Please proceed to the next section to upload some photos of your hairline.