Hair Transplant Dr. Cortez Pricing Testimonials Online Evaluation

Patient Form

Please fill the following form. Dr. Cortez will analyze your information and photos to determine if you are candidate for hair transplant.

First Name*

Last Name*

Email*

Phone*

Zip Code

Gender

Age

Past Medical History

Allergies
Diabetes
Hypertension
Cancer
Skin Disorder
Other

Medications

Previous Hair Loss Treatments

At what age you begin losing hair?

What areas would you like covered?

How did you learn about us?

Please upload photos of your head like the examples below:

Front of the Head

Top of the Head

Back of the Head

The full-back of the head must be visible in this photo.*

Left side

Right side