Please fill out completely and submit prior to your appointment with Dr. Rosanelli
Street Address Line 2
State / Province
Postal / Zip Code
What is your date of birth?
Have you ever had Hair Restoration Surgery or Scalp Surgery?
How many sessions?
When was your last procedure?
Have you ever used Minoxidil?
Have you every used Propecia?
Are you currently in good health?
No, please explain below
Explain answer regarding health
Please upload photos showing your hairloss, include front, sides and back of head if possible.
Is there a preferred day or time to speak with Dr. Rosanelli? We will call or email you to confirm.
What is your preference for a virtual consultation?
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