Hair Growth Client Inquiry

New Patient Information
Full Name

First NameLast Name
Date of Birth

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Date
Email Address
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Phone Number
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Digital Storage Authorization
By submitting this form, I voluntarily authorize Skin! Medical Aesthetics and its affiliated providers, employees, and authorized representatives to collect, store, and process the information I provide, which may include personally identifiable information and health-related information. I understand that my responses may be transmitted electronically and stored within secure internal systems, including encrypted cloud-based platforms such as Google Drive or similar technologies used for administrative and care coordination purposes.I acknowledge that authorized personnel, including patient coordinators and clinical staff, may access this information solely for legitimate business and healthcare operations, including appointment scheduling, consultation preparation, follow-up communication, treatment planning, and administrative tracking.I understand that while Skin! Medical Aesthetics implements reasonable administrative, technical, and physical safeguards consistent with applicable privacy and HIPAA standards to protect the confidentiality of my information, electronic transmission and cloud-based storage systems may carry inherent risks and absolute security cannot be guaranteed.By submitting this form, I expressly consent to the collection, storage, internal sharing, and use of my information for the purposes described above and authorize Skin! Medical Aesthetics to contact me via phone, text message, or email regarding scheduling, consultations, and services.

Photo Assessment
We need your photos to assess your scalp / hair condition and determine if you're a good candidate for treatment. Please follow the guidelines below and submit your photos.

All photos will be saved in our HIPAA compliant photo software. Photos are used for consultation purposes only. They will not be used or shared for any purpose other than this consultation.
Please upload your photos here.

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The Treatment Timeline
Our protocol includes:
- Scalp microneedling
- Scalp injections with PRP and PDGF
- Prescription topical serums and Exosomes for optimal hair growth
- At home red light therapy helmet (iRestore Elite)
We evaluate each patient thoroughly to ensure you are a good candidate for this treatment series, as we don’t want to waste your money or time!

Treatment timeline:

Month 1:
- Scalp preparation with prescription topical serums (contains Minoxidil, Dustasteride, and Tretinoin), GHK-CU peptide serum and Plated Exosome Scalp serum.
- Red-light helmet to use at home (15 minutes per day)
Month 2-4:
- Begin in-office treatments
- Continue topical serums and daily red light helmet
- Microneedling with PRP or PDGF injections. Each treatment is spaced 4 weeks apart for ideal growth.
Month 4-12:
- Continue at home topical serums and daily red light therapy.
- Maintenance treatments are performed annually depending on your growth/loss cycle.
One year package cost: $5999

Includes one year of treatments, scalp serums, and iRestore Elite helmet:
- Series of 4 in-office treatments
- Prescription Scalp Serum
- Plated Exosomes for Scalp
- iRestore Elite Red light helmet
Maintenance treatments after completing initial series: peform one microneedling session with PRP injections every 6 months.

What Happens Next
Our clinical team will review your history, goals, and photos within 7–10 business days. You’ll receive your personalized assessment by email, followed by scheduling instructions if you’d like to proceed.

If you'd like to schedule an in-person follow up consultation, Stephanie, our patient coordinator, will be reaching out to you via text for next steps. You can send an email to appointments@skindenver.co with questions or contact us directly via text or phone call at 720-227-1277.
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New Patient Information

Digital Storage Authorization

Medical and Hair Loss History

Photo Assessment

The Treatment Timeline

What Happens Next