Nader Medical Form - NADER MEDICAL

1Personal Details

2Transplant Details

3Photo Upload

Name*

First Last

Sex*

Age*

Phone Number*

Email*

Enter Email Confirm Email

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Job title:*

Ethnicity*

How did you hear about us?*

Family history of hair loss? (father or mother’s side, uncles, brothers)*

History of keloid formation (augmented scarring):*

Have you been diagnosed with any of the following:*

Diabetes type I or II

High Blood pressure

Low Blood pressure

Hypoglycemia or low blood sugar

Heart problems

Blood clotting problems

Ulcers or Gastritis

Asthma or breathing problems

Cancer

Sexually transmitted diseases

HIV or AIDS

Hepatitis

Psychological conditions

Thyroid problems

None

Describe psychological conditions and treatment:

Allergies to medication*

YES

Describe:

Allergies of any other kind*

YES

Describe:

Exercise?*

YES

Describe:

Do you smoke?*

YES

Describe:

Alcohol consumption?*

YES

Describe:

Vitamins or supplement consumption?*

YES

Describe:

Are you currently taking Oral Accutane?*

YES

Please list all oral medication currently taking for any treatment:*

Have you had a hair transplant surgery before?*

YES

Previous Surgery Details*

Please enter information for each of your past surgeries including:- Name of Doctor - Year of Surgery - Type of Surgery - Number of Grafts.

Have you had any micropigmentation in your scalp?*

YES

Describe:

Have you used Propecia / Proscar / Finasteride before?*

Have you used Minoxidil / Rogaine in the past?*

Have you used Laser comb or laser therapy for your hair?*

At what age did you first starting noticing hair loss?*

Please enter a number from 0 to 100.

What is your hair loss speed?*

What are your major areas of concern?*

Lowering hairline and/or temples

Frontal area

Mid area

Crown area (Vortex)

Scar revision

Other area that needs hair

Write down a brief history of your hair loss:*

How would you rate yourself in the Norwood Scale chart :*

When are you looking to move forward with your hair restoration?*

Do you have a budget in mind?*

Describe your hair restoration goals:*

Upload Photo Instructions

Ensure the room is evenly lit and bright. This is best accomplished in the daytime using natural light.
Do not use a flash. It obscures the scalp. If you think you need a flash, you need a brighter room.

Please note the following:

Maximum file size: 5 MB per image, images must measure less than 3200px x 3200px.

FRONT Photo

Drop files here or

Accepted file types: jpg, jpeg, png, Max. file size: 10 MB, Max. files: 1.

BACK Photo

Drop files here or

Accepted file types: jpg, jpeg, png, Max. file size: 10 MB, Max. files: 1.

Side Photo

Drop files here or

Accepted file types: jpg, jpeg, png, Max. file size: 10 MB, Max. files: 1.

TOP/CROWN Photo

Drop files here or

Accepted file types: jpg, jpeg, png, Max. file size: 10 MB, Max. files: 1.

Upload Additional Photo's

If you would like to upload additional photo's, please use this section.

Drop files here or

Accepted file types: jpg, jpeg, png, Max. file size: 20 MB, Max. files: 2.

Submit your photo's*

I acknowledge all information I have provided in this document is true, specific, and current about my health status.
By clicking "I agree", you allow Nader Medical to provide a recommendation based on the information and photos you provide. Your photos are confidential and will not be used without your permission.

I agree