If you live out of town and would like to investigate whether or not you are a good candidate for hair transplantation, please complete and submit an online assessment form and email us digital photos of your scalp following the guidelines below.

Once both your assessment form and photos have been received and reviewed by Dr. Barr, you will be contacted by a Client Coordinator to arrange for a preliminary phone consultation with Dr. Barr. Using your photos, combined with the information provided in your online assessment Dr. Barr can provide a reasonably accurate assessment of your hair loss pattern and make recommendations for a personalized restoration plan.

• Email us digital photos or scanned print photos
• Top of the scalp, left and right profiles, front hairline and back of scalp images are required
• Use bright, natural room lighting rather than a flash
• Take picture from a distance of 3-5 feet
• Ensure images do not exceed 4MB
• Please use jpg., jpeg file formats

Online Hair loss Assessment
Name	*
Last Name	*
Email	*
Telephone	*
Telephone #2
Prefered Method of Contact	Email Phone Land Mail
Address
State/Province
Zip Code/Postal Code
Country
City
Sex	Male  Female
Age
Hair Colour
Texture of hair	Thin   Medium   Thick
Waviness of hair	Straight   Wavy  Pretty curly
Family history of hair loss	Yes   No
At what age did you begin to notice hair loss?
Less than 20 21-30   31-40   41-50   Over 50
Baldness pattern
Class 1 Class 2 Class 2a Class 3   Class 3a   Class 3a vertex   Class 4 Class 4a Class 5 Class5a Class6   Class 7
Are you mostly interested in:
Information Pharmaceutical Treatment Surgical Treatment        Scheduling a session: Now  In the following two months In the following six months  After consultation
What would you like to achieve with hair transplantation (restore the front hairline, mid scalp, back, or your entire balding area)?
Have you ever consulted with a doctor about your hair loss condition? Yes   No ,  If Yes, With whom?
What treatment, if any, was recommended?
Have you ever had surgical hair restoration performed? Yes   No , If Yes, With whom?
Have you treated your hair loss with any of the following?
Rogaine: No  Past  Present Saw Palmetto No Past Present Propecia: No Past Present Other: No Past Present
Are you interested in receiving e-mail news about hair loss? Yes   No
More Information
How did you find us?
By a friend referral Forums Used Before   Television Web page Banner Link from another site Search Engine Not selected Yahoo Google Alta Vista Excite Lycos MSN Infospace Other Magazine / Newspaper Ad Radio Other