Prime Hair Consultation Form

1
Name* This field is required.
First Name
Last Name
2
Contact Information* This field is required.Please fill out all fields.
First Name
Last Name
Please Select
Please Select
Male
Female
Other
Gender
3
Date Of Birth* This field is required.
Date
Year
Month
Day
4
Phone Number* This field is required.
Area Code
Phone Number
5
Contact Information ContinuedPlease fill out all fields
Please enter your email
Please enter your address
Alberta Health Card# (if another province please specify):
Occupation
6
Family Doctor
Family Doctor
Family Doctor Phone Number
7
Phone Number* This field is required.
Please enter a valid phone number.
8
Date of birth* This field is required.
Month
Day
Year
9
Gender* This field is required.
Male
Female
Other
10
Alberta Health Card# (if another province please specify):* This field is required.
11
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
12
Family Doctor
13
Family Doctor Phone #
Please enter a valid phone number.
14
Occupation
15
Have you consulted other practitioners about your hair loss?* This field is required.
Yes
No
16
Where are you in your hair restoration process?* This field is required.
I've just started researching
I've used other treatments
I've had a hair transplant
I'm interested in non-surgical treatments ( Medication, SMP, Lasers, PRP, AlmaTed)
I'm interested in scheduling a surgical procedure within the next 90 days
I'm interested in scheduling a surgical procedure within the next year
17
What is your current hair loss concern? Please select all that apply* This field is required.
Starting to thin
Receding hairline
Naturally high hairline
Overall thinning
Bald spot forming in crown
Post pregnancy hair loss
Scar coverage
Beard
Eyebrows
Other
18
What hair restoration treatment(s) have you tried in the past/currently? Please select all that apply.
Hair Transplant Surgery
PRP - Platelet Rich Plasma
SMP - Scalp Micro-pigmentation
Oral Medication ( Finasteride, Dutasteride, Proscar, Minoxidil)
Topical Medication (Rogaine, Minoxidil, Medicated serum)
Hair Prothesis (Wigs, Toppers, Extensions)
Laser
Other
19
Oral Hair Loss Medication
Please Select
Please Select
Yes, Proscar
Yes, Propecia
Yes, Finasteride
Yes, Dutasteride
No
Are you currently or have you previously used oral hair loss medication?
If you have stopped taking an oral hair loss medication please explain why
20
Are you currently or have you previously used Propecia/Proscar/Finasteride?
Yes
No
21
If you stopped taking Finasteride/Propecia/Proscar, please explain why?
22
When was your previous hair transplant surgery?
Within the past 12 months
1 - 2 years
3 - 4 years
5+ years
23
What non-surgical options are you interested in?Please select all that apply
PRP- Platelet Rich Plasma
Oral/Topical medication
SMP- Scalp Micropigmentation
Laser hair therapy
Stem Cell Banking
AlmaTed Hair restoration system
Botox
CNC Hair restoration system (hair prosthetics)
Scalp Spa
Not sure yet
Other
24
What surgical option are you interested in?
FUT Transplant (strip method)
FUE Transplant (punch method)
Additional surgery, I have had a previous hair transplant
Beard
Eyebrow
Not sure yet
25
What surgical option(s) are you interested in?Please select all that apply
FUE Transplant (Punch Method)
FUT ( Strip Method)
Additional surgery, I have had a previous hair transplant
Beard
Eyebrow
Unsure
26
Please answer the next question using the Norwood and Ludwig Scale
27
Please select the number best associated with your current stage of hair loss
28
Please select the number best associated with your current stage of hair loss
29
What type of hair texture do you have?
Fine
Course
Curly
Straight
30
What type of hair density do you have?
Very thin
Thin
Average
Above average
31
Hair Type and Texture
Please Select
Please Select
Fine
Course
Curly
Straight
What type of hair texture do you have?
Please Select
Please Select
Very thin
Thin
Average
Above average
What type of hair density do you have?
Please Select
Please Select
Blonde
Light brown
Brown
Dark brown
Black
Auburn
Grey/white
What is your natural hair colour?
32
What is your natural hair colour?
Blonde
Light brown
Brown
Dark brown
Black
Auburn
Grey/white
33
Do you have family history of hair loss?
Mother
Father
Brother
Sister
Maternal Grandparent
Paternal Grandparent
Unknown
34
Do you have any allergies? If yes, please list.
35
Please list any medication you are currently taking.
36
Do you smoke/vape regularly
Yes
No
37
Do you drink alcohol regularly
Yes
No
38
General Health History
Do you have any allergies? If yes, please list.
Please list any medications you are currently taking
Are you being treated for any medical conditions at the present time or with in the past year? If yes, please explain
39
General Health History
Please Select
Please Select
Daily
Weekly
Occasionally
Never
Do you use cannabis products regularly?
Please Select
Please Select
Daily
Weekly
Occasionaly
Never
Do you drink alcohol regularly
Please Select
Please Select
Yes, Smoke
Yes, Vape
No
Do you smoke/vape tobacco products?
40
Do you use cannabis products regularly?
Yes
No
41
Are you being treated for any medical conditions at the present time or with in the past year?
Yes
No
42
Any additional information regarding your health you think is important for us to know?
43
Please attach clear photos of your hair/affected areas.

Helpful tip: Consider having a friend or family member assist you. Upload photos of your hairline, top of your head, sides, and back.
44
Image Upload
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Front, top, left, right, back - photo privacy
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45
How did you hear about us?
Doctor referral
Friend
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Online advertisement
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