At Bauman Medical Group, we value your privacy. View our privacy statement
View our privacy statement
WELCOME TO YOUR VIRTUAL CONSULTATION WITH DR. BAUMAN: Please read each of the following questions and indicate your answers. Once you complete this confidential patient form, click send to forward your information to Dr. Bauman.
(Please note: Since Dr. Bauman responds to every patient consultation personally, it may take up to two weeks to receive a reply. For more immediate attention, please call Bauman Medical Group toll-free at 1-877-BAUMAN-9).
What is your current hair loss concern? Starting to thin Advanced stage of thinning Overall thinning Receding hairline Bald spot forming in crown Little or no hair on top of the scalp Itching or flaking scalp Increased shedding Missing, damaged or sparse eyebrows Weak or sparse eyelashes Damaged or traumatized eyelashes Post-Plastic Surgery Hair Loss Visible Scar
Please check the box which most closely matches your hair loss pattern. Norwood 2 Norwood 2a Norwood 3 Norwood 3a Norwood 3 Vertex Norwood 4 Norwood 4a Norwood 5 Norwood 5a Norwood 6 Ludwig 1 Ludwig 2 Ludwig 3 Other (describe)
Norwood 2 Norwood 2a Norwood 3 Norwood 3a Norwood 3 Vertex Norwood 4 Norwood 4a Norwood 5 Norwood 5a Norwood 6 Ludwig 1 Ludwig 2 Ludwig 3
Hair-Health History I have been diagnosed with alopecia totalis or alopecia universalis. I suffer from active trichotillomania (hair pulling).
What therapies have you tried?
If you camouflage your thinning/balding hair, which methods have you used?
Age:
Gender: MaleFemale
What is your family's history of hair loss? Mother Father Maternal grandparents Paternal grandparents Brother/sister Don't know
Your personal hair restoration objectives (check all that apply): Hairline restoration Increase in frontal density Crown coverage Stop hair loss / decrease shedding Touch-up, refinement or correction of previous procedure Scar Coverage Other (please explain):
Hair restoration solutions of interest: Dr. Bauman's Multi-Therapy Approach Surgical hair restoration (Follicular-unit micrografting, Linear harvest) Surgical hair restoration (Follicular-unit extraction: FUE/FOX) Medical therapy (Propecia, Minoxidil/Rogaine) Laser hair therapy (laser hood, laser comb) Nutritional supplementation Post-Plastic Surgery hair transplantation (describe below) Eyelash transplantation Eyebrow transplantation Beard/moustache transplantation Body-hair transplantation Scar coverage Other (please specify):
Where are you in the hair restoration process? I've started researching my hair restoration options I'm interested in starting non-invasive treatment (Propecia, Minoxidil /Rogaine, Laser Therapy) I've had a hair transplant before I've had a consultation with another doctor I'm interested in scheduling a surgical procedure within the next ninety days I'm interested in scheduling a surgical procedure within the next year
What is your current "Plan of Action?" (Check all that apply): I am interested in visiting the Boca Raton, Florida USA office for a procedure or other treatment. (Please indicate your time frame:) I would like to schedule an in-person consultation with Dr. Bauman in Boca Raton, Florida USA. I'm interested in completing a "Virtual Consultation" and having a preliminary evaluation by Dr. Bauman using email and photos. I will not be able to visit Dr. Bauman in Boca Raton, Florida USA for an evaluation, procedure or other treatment in the near future. Other (describe):
How to contact you: (* Indicates required field)
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While every effort is made to keep your transmission confidential, the internet and email communication are inherently subject to breaches of privacy. To review our privacy statement, click the link at the bottom of this page. If you would prefer to print and fax your completed form to our office directly, you can fax your consultation information to 561-394-4522.
