Virtual Pre-Consultation

If you would like an initial review of your hair loss situation, we would gladly do a preliminary review of your case through our Virtual Pre-Consultation. We treat your photos and personal information as highly confidential, and it will not be sold or shared with any third party. Submitting your details to Virtual Consultation is free.

As this is only a preliminary evaluation, Virtual Pre-Consultation does not take the place of a full, in-person consultation that includes a full physical examination of your scalp with microscopic evaluation, photography, and a medical workup. A full in-person consultation or a Skype video consultation one-on-one with Dr. Prasad can be arranged through our office for a fee. The consultation fee is deducted from your total treatment/procedure cost.

This form and any reply to it does not take the place of an actual in person consultation, nor does it constitute a doctor-patient relationship. The information you provide enables us to give you initial suggestions and guidance. Fill-in your details and pictures below to start Virtual Pre-Consultation.


Contact Information

How to contact you: (* Indicates required field)

*First Name:
*Last Name:
*Phone Number:
*Email Address:
Street Address:
City:
*State / Province:
ZIP / Postal Code :
*Country:

Preferred Contact Method:

  Phone     Email



Best Time to be Contacted: 

Best Day to Be Contacted: 

Please send me updates about Hair Regeneration

Help us understand your hair loss

Gender: MaleFemale
Age:

Please select the box that most closely matches your hair loss pattern.

Norwood Hamilton Scale for Male Hair LossLudwig Scale for Female Hair Loss


What treatments have you tried?

Propecia (finasteride)Rogaine (minoxidil)Saw palmetto/other herbs, supplementsHair TransplantationLaser therapyOther (describe)

Is there a history of baldness/thinning hair in your family? YesNo

Has your hair loss/hair thinning become more apparent recently? YesNo

On a scale from 1 to 10 (10 being most urgent), how would you rate the urgency to treat your hair loss?

1097654321

Message/Comments:

Photo submission instructions

Please follow these examples for the angles of your head needed for evaluation. All submitted images and information will be kept confidential, not be used or sold by any third parties, nor be broadcast publicly.

Angle 1
angle 1

Angle 2
angle 2

Angle 3
angle 3

Angle 4
angle 4

Our office will review your information and contact you.

While every effort is made to keep your information confidential, the internet and email communication are inherently subject to breaches of privacy. Our privacy statement is viewable before your details listed here are submitted

Review and Submit

x

Disclaimer and Privacy Statement


Your submitted information and images, as well as all subsequent correspondence do not constitute a doctor-patient relationship. Virtual consultation is meant for preliminary evaluation, inquiry, and appointment scheduling only. Virtual consultation is not a substitute for an in-person, in-office physical examination by the doctor(s) or any medical personnel. A formal consultation can be scheduled after the submission of your information, by contact through phone, or through correspondence. A formal consultation only takes place only within our offices with a physical exam by the doctor(s), or through a one-on-one video consultation through Skype.


Your information and submitted photos will be used for your personal medical file only, and will not be used or sold for any promotional purposes, including our own websites, videos, or any third party. Given that the internet and email have potential security issues, we are not liable for any breach that gives an unauthorized party access to your information and images.


Prospective patients must disclose any medical information from previous consultations or diagnoses from other physicians. Any withheld information on current or past medical conditions that may affect our prescribed treatments and procedures frees Prasad Cosmetic Surgery from any liability.


Should you choose to become a Prasad Cosmetic Surgery patient, the treatment does not claim to universally benefit all patients, and treatment results will vary among individual patients. No guarantees of effectiveness are claimed or promised by Prasad Cosmetic Surgery.