Free
Consultation Form

http://www.ljihr.com/consultation-form/

For a virtual consultation, please complete the consultation form below and attach photos. A virtual consultation is only possible if the required photos are submitted.

Photos must not exceed 4MB (4,000kb) each. Please resize photos that exceed this limit. Acceptable photo file types are jpg or jpeg.

To complete the free online hair transplant consultation, please provide photos showing the following angles:

San Diego Hair Transplantation Consultation

Name (required)

Age (required)

Email (required)

Phone (required)

Address (required)

City (required)

State (required)

Zip (required)

How did you find LJIHR? (required)

If "other", where do you hear about us?

Brief hair loss history (required)

Have you had a hair transplant procedure? If "Yes", please provide details: date(s) of procedure, number of grafts, how many sessions, which clinic, etc.

Are you taking Propecia? If "Yes", for how long?

Are you taking Rogaine? If "Yes", for how long?

Expectations from the procedure. (required)

Approximate date you would prefer to have your procedure?

Preferred method of contact

Required Photos

Photo 1

Photo 2

Photo 3

Photo 4


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LJIHR

$500 Savings for New Patients!

MEN'S HAIR LOSS SCALE

Click on the image that most resembles your hair loss condition.

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CONTACT INFORMATION

Provide your age, first name and email address.

Age First Name
Email

MEDICAL HISTORY

Have you used the following medication?

Rogaine PastPresentNever

Propecia PastPresentNever

QUESTIONS OR COMMENTS

List any additional questions and comments below.

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