TrichoStem Virtual Pre-Consultation

Want to know if TrichoStem® Hair Regeneration is right for you before traveling to one of our Centers? Virtual Pre-Consultation will give you a free, preliminary evaluation of your hair loss to see if the treatment is right for you. Submitting your personal details for our review is free of charge, and will be treated with the utmost confidentiality.

This form and any reply to it does not take the place of an actual in-person consultation, and does not constitute a doctor-patient relationship. The information you provide enables us to give you initial suggestions and guidance. A proper in-person consultation which includes microscopic scalp analysis, photography, and a medical workup; or a one-on-one Skype video consultation with a TrichoStem® doctor can be arranged through our office for a fee. The fee for a formal consultation is deducted from your treatment/procedure cost.

Provide your details and photos 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 TrichoStem

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?
Platelet-rich plasma (PRP) injectionsPropecia (finasteride)Rogaine (minoxidil)Saw palmetto/other herbs, supplementsHair TransplantationLaser therapyOther (describe)

Does baldness/thinning hair run in your family? Yes  No

Has your hair thinning become more noticeable recently? Yes  No

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

10   9   8   7   6   5   4   3   2   1   

Message/Comments:

Photo submission instructions

Submit own photos of your hair loss for analysis by doctor at one of the Trichostem Hair Regeneration Centers. 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 publically.

Angle 1


Angle 2


Angle 3


Angle 4


A TrichoStem medical provider will review your information and contact you.

While every effort is made to keep your transmission confidential, the internet and email communication are inherently subject to breaches of privacy. Please review our Disclaimer and Privacy Statement before submitting your information.


Review and Submit

Live Virtual Consultation with a Trichostem™ Doctor

Trichostem doctors like founder Amiya Prasad, M.D. are available for a live video consultation through Skype. Live Virtual Consultation through Skype can be coordinated after submitting your details.


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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 TrichoStem™ and Prasad Cosmetic Surgery from any liability.


Should you choose to become a TrichoStem™ Hair Regeneration/ 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 TrichoStem™ Hair Regeneration or Prasad Cosmetic Surgery.