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We are a medical practice dedicated solely to hair restoration. All information shared with us will be treated confidentially and for the sole purpose of setting up your consultation. You will not be added to any mail solicitation list, nor will your information be passed on to any other entities. Please be as thorough as possible in filling out the form below.

Sincerely,
Brian O. Goertz, MD

“I can’t tell you how happy I am that I had this transplant.” – Wayne L. Zinter

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Preferred Appointment:
	Monday | AM	Monday | PM
	Tuesday | AM	Tuesday | PM
	Thursday | AM	Thursday | PM
	Friday | AM	Friday | PM
Age:
	Male Female TG
Interested In:	Scalp Hair Restoration Eyebrow Transplant Facial Hair Transplant Pubic Hair Transplant Scalp Scar Repair Hair Transplant Repair
Requesting:	Free Consult Information
Hair Loss Stable?	Yes No
Hair Loss Scale:	Unsure 2 2A 3 3A 3V 4 4A 5 5A 5V 6 7	This is to reference hair loss for men only. See chart below for more information.
Comments:
Norwood Hair Loss Classification (Applies to Male Hair Loss Only)