BOSLEY The World’s Most Experienced Hair Restoration Expert®

First Name :

Last Name :

Address :

City :

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Zip :

Date Of Birth :

Please enter in this format MM/DD/YYYY

Gender

Age :

Age Group :

Minor (Below 18)

Adult (18 and Above)

Marital Status :

SingleDivorcedSeperatedMarriedWidowed

Occupation :

I am interested in :

Hair

Restoring My HairPreserving My HairScalp Micro PigmentationEyebrow RestorationPlease check all that apply

Cool Sculpting(Non-invasive Fat reduction)

AbdomenFlanks(Love Handles)ThighsSubmental (Double Chin)Please check all that apply

Bosley can contact me as follows

Cell Phone :

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Home Phone :

Home Phone:

Same as above

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Work Phone :

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Email :

By signing below, I consent to Bosley using automated technology to contact me at the numbers provided. I understand that consent is not required to purchase goods or services from Bosley.

Emergency Contact

Name :

Relationship :

Phone No :

Initials

Patient's Initials

Guardian's / Parent's Initials

INITIAL THAT YOU HAVE FILLED IN THE ABOVE INFORMATION AND THAT THE INFORMATION IS ACCURATE

Hidden Details

Key

Pre-Fill Key

Date

Health Information

Have you ever had any reaction to a medication?

Allergic Reaction to Medications List

Have you ever had any reaction to local anesthesia

Do you take any prescribed medications regularly?

Blood thinners or aspirinBlood pressure or heart medicineDiabetes medicationAsthma medicationThyroid medicationHormone replacement therapy, female or maleSeizure medicationHIV Prevention MedicationAuto Immune Antiviral / AntibioticOtherI do not take any prescribed medications regularlyPlease check all that apply

Please list all medications you take:

Have you had any of the following surgical procedures?

Cosmetic surgery of the face, head or neckHeart surgery or proceduresScalp surgeryBrain surgery, including shuntsJoint replacement or other implanted devicesOrgan replacement/transplantOther surgical proceduresNone of the abovePlease check all that apply

Scalp surgery - What Type?

Other surgical procedures - What Type?

Have you ever been treated for any of the following medical conditions?

Any skin condition, including scalpHeart disease or heart attackHigh blood pressureStroke, TIA or "Mini-Stroke"Asthma or other breathing conditionDiabetes or pre-diabetesThyroid abnormalitiesAbnormal bleeding or bleeding disordersAbnormal wound healing, abnormal scarring or Keloid scarsHIV infection or hepatitisOther Medical ConditionsNone of the AbovePlease check all that apply

Other Medical Conditions

Initials

Patient's Initials

Guardian's / Parent's Initials

INITIAL THAT YOU HAVE FILLED IN THE ABOVE INFORMATION AND THAT THE INFORMATION IS ACCURATE

Hair Loss Info

What do you want to do?

Restore your hairMaintain your hair

What areas would you like to treat?

Receding hairlineTop of headScars on scalpEyebrowsOther areasPlease check all that apply

Other areas would you like to treat

When did you first become aware of your hair loss?

Who in your family suffers from hair loss?

Father's side: Father, Uncles/Aunts or GrandparentsMother's side: Mother, Uncles/Aunts or GrandparentsSiblings: Male or FemaleOther RelativesNone of the abovePlease check all that apply

Other relatives

What steps, if any, have you already taken to address your hair loss?

Finasteride/PropeciaMinoxidil/RogaineLaserHair transplantPlatelet Rich PlasmaScalp Micro PigmentationWigsToupeeFibersHair SystemVitaminsShampooConcealersOtherNone of the abovePlease check all that apply

Other

What research have you done regarding your hair loss and what have you learned ?

What physical activities do you participate in?

Baseball	Basketball	Soccer	Tennis
Weight lifting	Spin Class	Walking	Running
Water sports	Biking	Golf	Football
Yoga	Pilates	Other	None of the above

Other

When does your hair loss affect you the most?

When I meet new people	My overall appearance
When others make comments	When I see old friends
At beach or swimming	On a windy day
When I get dressed up	My self-esteem
When I see pictures/videos	In my social life
When I have to wear a hat	When I am at work
Other	None of the above