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*First Name   *Last Name
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*Date of Birth (mm/dd/yyyy)   *Your Age
*Sex  Male Female        *Emergency contact

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The name of the person to thank for Referring you:

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.

How much knowledge do you feel you about the options available to treat hair loss:
Very Little         Moderate        Extensive

Have you consulted with other Clinics:
Yes        No

In what form(s) of treatment are you most interested:
Surgical       Non Surgical Medical       Non Surgical Cosmetic

Which of the following would you find most helpful:
In depth Consultation       Meeting Old Patient       Talking to Old Patients       Seeing a Patient During Surgery

Hair Loss History

At what age did hair loss begin?
How fast does hair loss appear to be progressing at this time?

Which relative has the most hair loss:
Father      Uncles      Grandfathers       Brothers

Use the diagrams below (Norwood Classification of Hair Loss) to answer the next few questions:

Which diagram has the hair loss pattern that is closest to what you have now?
Which diagram has the hair loss pattern that you might progress to in the future. (20-40 years)
Which diagram has the hair loss pattern that is closest to your relative with the most hair loss

pel1
pel2


Check the description below that best describes the present hair condition in each area of your scalp:

Hairline: Normal Thinning Very Thin Bald
Frontal Area: Normal  Thinning Very Thin Bald
Top (middle): Normal Thinning  Very Thin Bald
Crown (Back): Normal Thinning Very Thin Bald

Hair Characteristics:

Hair Color: Blonde White Black  Salt and Pepper Brown
Skin Color: Fair  Medium   Dark    
Hair Curl: Straight Slight Wave Wavy Curly  
Hair Thickness: Very Fine Fine Medium Medium Coarse Coarse

Past Surgery History:

  Date Number of Grafts Physician
Surgery #1
Surgery #2
Surgery #3

Current Goals:

Medical Loss History:

Do you have a History of:
1 Yes   No Bleeding problems (nose bleeds, gum bleeds, easy bruising, etc)
2 Yes   No Poor or abnormal healing (wide scars, raised scars, larger scars, slow healing)
3 Yes   No HIV positive (confidential but needs to be known to protect patient and staff)
4 Yes   No Blood transfusions
5 Yes   No Liver problems (hepatitis)
6 Yes   No High blood pressure
7 Yes   No Heart Disease (heart attack, arrhythmia or irregular pulse, heart murmur, etc)
8 Yes   No Lung disease (asthma, pneumonia, chronic bronchitis)
9 Yes   No Kidney, Bladder, Prostate disease
10 Yes   No Stomach disease (ulcers, heartburn, etc)
11 Yes   No Neurological Disease (Stroke, Seizure, Fainting)
12 Yes   No Do you have any artificial joints, artificial heart valves, metal pins?
13 Yes   No Emotional problems (depression, anxiety, panic disorder, etc)
14 Yes   No Glaucoma
15 Yes   No Have you been told you need antibiotics PRIOR To Surgery?

Please give details to questions answered [yes] above:

Average weekly alcohol intake:

Average weekly cigarette use:  

Are you allergic to the following medications that we use in this surgery, if so list below: (Penicillin, Novocain, Xylocaine, Codeine, Valium, Skin Tape, Soaps) Other:

List any other medications to which you are allergic:

List all prescription or non-prescription medications, drugs, or vitamins you take either regularly or occasionally: (Including Rogaine, Vitamin E, over the counter pain and arthritis medications like Advil or Motrin)

Please list any operations, hospitalizations, or medical illness not listed not mentioned above:

Pre-Operative Hair Transplant Instructions

Please take blood pressure/ cardiac medication as prescribed prior to your procedure.

  • Do Not take aspirin, anti-inflammatory medications, Vitamin E, garlic tablets, Supplements or anything else that thins the blood 2 Weeks 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 and Vitamin K 100 mc G daily for 2 weeks prior to your surgery.
  • Do not drink alcohol for 2 weeks prior to surgery. Alcohol can also thin the blood and cause the procedure to be more difficult AND lengthy.
  • Wash your hair the morning of surgery. Do not use hair spray the morning of surgery.
  • Do not cut the hair on the back of the head short 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 T-shirt as it is difficult to pull over the head 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 secure 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 OR DRIVE A LONG DISTANCE THE NIGHT OF SURGERY. It is suggested that you spend the night and return home the following morning.

Deposit and Payment Policy: We require a $1000 deposit two weeks in advance to hold and confirm your appointment. Please make the check payable to SUMMIT HAIR RESTORATION.. This deposit is non-refundable unless we are notified 3 days prior to surgery. Payment is due in full on the day of surgery by cash, check, Visa or Master Card.

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 14 DAYS PRIOR TO SURGERY

ADVIL ALCHOHOL ALKA SELTZER ALLEVE
ANACIN BUFFERIN BRUFEN CEPHAL GESIC
ANAPROX CHERACO CONGESPRIN COPE TABS
ANAPROXIN CLIORIL CORICIDIN COUMADIN
ASA DARVON EASPRIN EMPIRIN ECOTRIN
ASCODEEN DOLOBID EMPRAZIL EXCEDRIN
ASCRIPTIN DRISTAN FIORINAL GINGO BILOBA
ASPIRIN FELDENE GARLIC PILLS INDOCIN
CHILDREN’S ASPIRIN IBUPROFIN MEDIPRIN
DARVON w/MECLOMEN INDOMETHACIN MIDOL
FOUR WAY COLD TABLETS MOTRIN NALFON
GLUCOSAMINE CHONDROITIN NAPROSYN NORGESIC
QUAGESIC NURPIN PERCODAN PERSANTINE
ROBASISAL SINE AIDE SINE OFF TRANDATE
RUFIN TRENTAL TRIGESIC TRILISATE
VANQUISH VITAMIN E VOLTARIN ZACTRIN
ZORPRIN ALL DIET PILLS    

IF YOU HAVE ANY QUESTIONS PLEASE CONTACT OUR PATIENT COORDINATOR


POST OPERATIVE INSTRUCTIONS

Hair restoration is a delicate procedure. Your adherence to the following instructions is essential for optimal results.

CLEANING AND SHAMPOOING THE MORNING AFTER SURGERY (TRANSPLANTED AREA) NO Medicated or Baby shampoo.
  • For the next 7 days shampoo your hair twice daily, once in the morning and once in the evening.
  • Lather up the shampoo on the palm of your hand
  • Gently pat the shampoo on the grafted area and let it sit for 10 minutes. (DO NOT RUB)
  • Gently cup rinse the shampoo with cool water with head tilted back. (Do not have direct water pressure)
  • Gently pat dry the graft area with towel. DO NOT RUB THE GRAFTS TO DRY THEM
  • After your sutures are removed you CAN shampoo your hair normally.

Wash the sutured donor area daily with a gentle but firm rubbing in a side-to-side direction. You can wash more aggressively in the sutured donor area. Sutures should stay in for 7-10 days depending on your skin characteristics.

Gently spray the Post op spray to the grafted area every 30-60 minutes while awake until the bottle is empty. Do not blot off, and make sure it does not get in your eyes.

Sleep on your back using 2-3 pillows or a neck roll pillow to keep head elevated above the heart for 3 nights, If slight bleeding occurs from the graft site or donor site, apply gentle but firm pressure to the area with the gauze provided or a clean cloth. APPLY EVEN PRESSURE WITH THE PALM OF YOUR HAND FOR 5 MINUTES. The bleeding should stop. If it does not, call us. If the bleeding continues and for some reason you can’t reach us, go to the nearest Emergency Room.

Place a towel on your pillow for the first 2-3 nights to protect your linens in case of slight bleeding.

Apply ice to the FOREHEAD only for 15 minutes 3-4 times a day for the first 3 days. This will decrease the chance of swelling. On occasion, swelling can still occur (in 10% of patients). It is not dangerous, is painless, and will not affect the growth of the grafts.
Bend at the knees instead of bending over at the waist when tying shoes and picking up objects. Keep your head above your heart at all times.

Folliculitis on rare occasions may develop at the graft site. These look similar to acne with pimple-like lesions. If this happens, apply moist warm soaks and antibiotic ointment to the areas 3 times a day. PLEASE NOTIFY US IF THIS OCCURS, AS WE LIKE TO PRESCRIBE SPECIFIC MEDICATION FOR THIS PROBLEM.

If you experience any post op itching you can use the following: Jojoba Oil (Bath & Body has this product), Botan Oil Shampoo by Nexus, and Bio Jojoba Shampoo.

Numbness above the suture line and at the graft sites most likely will occur. This is normal and will begin to resolve in 6-8 weeks. However, in some people it can take as long as one year.

Do not drink alcohol for 48 hours after the surgery. Alcohol thins the blood and may cause bleeding.

No exercise for 5 days after the procedure. It could result in increased swelling or lost grafts. After 5 days mild exercise can be resumed, and after 10 days normal exercise can be resumed.

You should avoid swimming for 1 week after surgery.
Do not sunburn the grafted area. The skin of the grafts may burn easily. It is OK to go into the sun but do not sunbathe without some protection for this sensitive skin.

A Prescription for Pain Medications will be given to you on the day of your procedure.

NON-PRESCRIPTION MEDICATIONS: You may take TYLENOL or MOTRIN instead of the prescription pain medication.

 

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Summit Hair Restoration,
3023 Eastland Blvd. Suite 113
Clearwater, Florida 33761
Phone: 888-GRECOHT
Fax: 727-791-3629

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