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Virtual Consultation

Please fill out the below form to schedule your virtual consultation at Cooley Hair Center

First Name*
Last Name*
Phone*
Email*
D.O.B.
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Day
Year
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Age
Please enter a number from 18 to 99.
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
*Information provided will no be shared or sold.
How did you hear about us?
Please be specific. This helps us better understand how patients find us.
Preferred Procedure Method
Have 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?
If no, have you taken it in the past?
If yes, for how long?
Why did you stop using it?
Have you used Rogaine/Regaine/Minoxidil or products with minoxidil?
- Yes
- No
If yes, for how long?
If no, have you used it in the past?
If yes, for how long?
Why did you stop using it?
What is the approximate date you are hoping to have a procedure if you are a candidate?
Tell us the history of hairloss in your family
Tell us about your personal hair loss history
Please describe your specific goals, such as hairline reconstruction, temples, crown, etc.
Photo Upload Instructions
1. 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.
Example
Back photo with donor exposed*
Max. file size: 5 MB.
Example
Back photo*
Max. file size: 5 MB.
Example
Left side photo (90 degrees from camera lens)*
Max. file size: 5 MB.
Example
Right side photo (90 degrees from camera lens)*
Max. file size: 5 MB.
Example
Top photo (looking down, chin should be touching your chest)*
Max. file size: 5 MB.
Example
Additional photos (add photos you feel will help us to understand your problem)
Max. file size: 5 MB.
Terms*
Please check box to agree
By 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.
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Ultra-Refined Hair Transplant Surgery For Men & Women

Get your self-confidence back. Of course, hair restoration is something you do for yourself….not to please anyone else. When you have surgical hair restoration at Cooley Hair Center, you will see not only new hair but renewed self-confidence and higher self-esteem. It is an investment in yourself!

It is an investment in yourself!

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*Not an actual Cooley Hair Center patient.

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TODAY

When you have surgical hair restoration at Cooley Hair Center, you will see not only new hair but renewed self confidence and higher self-esteem. It is an investment in yourself!