Appointment Forms To save time during your appointment, you can fill out these forms at home and then bring them with you.Click the links below to access forms for new patients. Notice of Privacy Acknowledgement of Receipt of Notice of Privacy Practices Patient Information Patient Registration Medical History Office Policy Patient Information Release Authorization (Optional) (Due to the popularity and desirable services of Dr. Cooley, Consultations can be booked out 2-3 months with surgeries booked out 6-12 months after that. We are excited to develop a personal relationship with you to provide you personalized care.) * "*" indicates required fields EmailThis field is for validation purposes and should be left unchanged.First Name*Last Name*Phone*Email* D.O.B. 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How did you hear about us?Please select oneHair Transplant Mentor™/Joe TillmanIAHRSBald Truth Talk ForumYoutubeInstagramFacebookTwitterGoogleBingYahooHair Loss Experiences ForumHairlosscure2020Patient ReferralTVRadioHair Restoration NetworkYellow PagesPlease be specific. This helps us better understand how patients find us.Preferred Procedure MethodPlease select oneOpen to recommendationsPrefer FUT but will consider FUEPrefer FUE but will consider FUTOnly prefer FUEOnly prefer FUTInterested in a combination approachHave you had a hair transplant before? Yes No Which method was used?Please select all that apply. FUE? FUT? Plugs? Flap? Scalp Reduction? Are you currently using Proscar/Propecia/Finasteride? Yes No If yes, for how long?Please select oneLess than 6 monthsMore than 6 months1 year or moreIf no, have you taken it in the past?Please select oneYesNoIf yes, for how long?Please select oneLess than 6 monthsMore than 6 months1 year or moreWhy did you stop using it?Have you used Rogaine/Regaine/Minoxidil or products with minoxidil? Yes No If yes, for how long?Please select oneLess than 6 monthsMore than 6 months1 year or moreIf no, have you used it in the past?Please select oneYesNoIf yes, for how long?Please select oneLess than 6 monthsMore than 6 months1 year or moreWhy did you stop using it?What is the approximate date you are hoping to have a procedure if you are a candidate?Within 2 months2-4 months5-7 months8 months or laterTell us the history of hairloss in your familyTell us about your personal hair loss historyPlease describe your specific goals, such as hairline reconstruction, temples, crown, etc.Photo Upload Instructions1. Ensure the room is evenly illuminated and bright. This is best accomplished mid-day using natural light and lots of windows. If this is not possible, consider your washroom. 2. Do Not Use Flash. It creates false images that obscure necessary details. If you think you need flash, you need better lighting, not flash. 3. Be sure that your final photos clearly show the problem you are dealing with. If you cannot see the problems in your photos, neither can we. 4. Make sure your hair style is not covering the problems. For example, if you are bald and style your hair with a comb over, this will not allow us to see how bald you are. Front Photo*Max. file size: 5 MB. ExampleBack photo with donor exposed*Max. file size: 5 MB. ExampleBack photo*Max. file size: 5 MB. ExampleLeft side photo (90 degrees from camera lens)*Max. file size: 5 MB. ExampleRight side photo (90 degrees from camera lens)*Max. file size: 5 MB. ExampleTop photo (looking down, chin should be touching your chest)*Max. file size: 5 MB. ExampleAdditional photos (add photos you feel will help us to understand your problem)Max. file size: 5 MB. Terms* Please check box to agreeBy clicking "I agree" you are giving your consent to Cooley Hair Center to use the photos for evaluation. Your photos will only be used for this purpose and will not be shared publicly without your written permission. SourceMediumCampaignContentTerm
To save time during your appointment, you can fill out these forms at home and then bring them with you.Click the links below to access forms for new patients.