Center For Sight

Upcoming Seminars

Hair Restoration Form

The best way to evaluate a patient is to arrange a personal, in-depth consultation. However, this is impossible for many patients who live out-of-state or in other countries. For this reason we have developed the online consultation.

By completing this form about your thinning areas we can provide you with a preliminary plan for surgically restoring your hair. After submitting this form, Dr. Greco may request images of your hairline via email. Once your photos and questionnaire are reviewed, we will telephone you to discuss your questions or concerns regarding the procedure. You will also be given a suggested treatment plan and costs involved.

Please note, all information is required unless otherwise stated.

New Patient Information

ex. (555) 555-5555
ex. (555) 555-5555
For communication regarding your consultation
 
 

Procedural Information

Making a choice to do something about your hair loss is a very important decision. It is important to feel comfortable and well educated about your options. The following information will help us in this process.

Hair Loss History

 
 

Uncles
Norwood I
Norwood II
Norwood II A
Norwood III
Norwood III Vertex
Norwood III A
Norwood IV
Norwood V
Norwood IV A
Norwood VI
Norwood VII
Norwood V A
Check the description below that best describes the present hair condition in each area of your scalp:
Hair Characteristics:

Past Surgery History

Date:
# of Grafts:
Physician:
Date:
# of Grafts:
Physician:
Date:
# of Grafts:
Physician:

Medical History

Do you have a history of any of the following? (Check all that apply)

 
 


Pre-Operative Hair Transplant Instructions

  • Please take Vitamin K twice a day one week prior to your scheduled surgery. This can be found at your local GNC store.
  • Do Not take aspirin, anti-inflammatory medications, Vitamin E, garlic tablets or anything else that thins the blood 14 days before surgery. Many over the counter medications like Advil, Alka-Seltzer, Bufferin, Excedrin, Empirin, should also be avoided. If you are not sure call our office. As little as one aspirin can thin the blood for 2 weeks.
  • We recommend you start taking 2000mg of Vitamin C daily for 2 weeks prior to your surgery.
  • Do not drink alcohol for 10 days prior to surgery. Alcohol can also thin the blood and cause the procedure to be more difficult.
  • Wash your hair the morning of surgery. Do not use hair spray the morning of surgery.
  • Do not cut the hair short on the back of the head before surgery. This will make it more difficult to hide the suture line. This hair should be about one inch in length.
  • Drink plenty of fluids and eat a normal meal the night before and morning of surgery.
  • Wear comfortable loose pants and a button-down shirt the day of surgery. Do not wear a tee-shirt, as this is difficult to pull over the head after surgery.
  • Bring a baseball type hat to wear after surgery.
  • You will be given a sedative to help you relax through the surgery. It is therefore recommended that you have someone drive you home after the surgery.
  • Travel Plans: If you are from out of town please make your plane, hotel, and car reservations early in order to receive the best rates. If you need help with reservations we will be happy to assist you.
  • IF YOU LIVE OUT OF TOWN IT IS NOT RECOMMENDED THAT YOU FLY HOME OR DRIVE LONG DISTANCES IMMEDIATELY AFTER SURGERY. It is suggested that you spend the night and return home in the morning.
Deposit and Payment Policy: We require a $1000.00 deposit to hold and confirm your appointment. Your deposit will be credited toward your procedure. Please mail your deposit to us at least two weeks in advance. Make the check payable to Summit Hair. This deposit is non-refundable unless notified 10 days prior to surgery. Payment is due in full on the day of surgery by cash, check, Visa or Master Card.

Partial List Of Medications to be Discontinued 14 Days Prior to Surgery

Advil
Alchohol
Alka Seltzer
All Diet Pills
Alleve
Anacin
Anaprox
Anaproxin
Asa
Ascodeen
Ascriptin
Brufen
Bufferin
Cephal Gesic
Cheraco
Children's Aspirin
Clioril
Congesprin
Cope Tabs
Coricidin
Coumadin
Darvon
Darvon w/ Meclomen
Dolobid
Dristan
Easprin Empirin
Ecotrin
Emprazil
Excedrin
Feldene
Fiorinal
Four Way Cold Tablets
Garlic Pills
Gingo Biloba
Glucosamine Chondroitin
Ibuprofin
Indocin
Indomethacin
Mediprin
Midol
Motrin
Nalfon
Naprosyn
Norgesic
Nurpin Percodan
Persantine
Quagesic
Robasisal
Rufin
Sine Aide
Sine Off
Trandate
Trental
Trigesic
Trilisate
Vanquish
Vitamin E
Voltarin
Zactrin
Zorprin

All information provided is private and not sold or released to third parties.