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Virtual Consultation Form

Welcome to your virtual consultation with Dr. Malouf:

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. Malouf.

(Please note: Since Dr. Malouf responds to every patient consultation personally, it may take up to two weeks to receive a reply. For more immediate attention, please call Dr. Malouf at (214) 373-3376.

How to contact you: (* Indicates required field)

* First name:
* Last name:
* Best telephone number:
* Email address:
* Confirm email address:
* Street Address:
* City:
* State/Province:
* Postal code:
Country:

Age:

Gender:

Please check the box which most closely matches your hair loss pattern.



 

What therapies have you tried?

Past
 Currently
Propecia
Rogaine (minoxidil)
Saw palmetto/ other herbs, supplements
Hair Transplantation
Laser therapy
Special shampoo
Other
(Please specify):

Your personal hair restoration goals (check all that apply):

What is your timeline in the hair restoration process?

What is your primary concern or question at this point? ( add any additional comments below)

How did you hear about this website?





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 (214) 346-0371.
 
 
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