Appointment Request Online | OC Hair Restoration

Full Name*

Email Address*

Phone Number*

Date of Birth*

What is your city and state?*

Gender*

Male
Female

Preferred method of contact

Phone
Email

If by phone, can we leave a message?

Yes
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Best time to call

Morning
Afternoon
Whenever

What are your main areas of concern?

Under ideal conditions, when would you be able to move forward? (select one)

Right Away
In a month
Within 6 months
In a year

Do you have a budget in mind?

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No
Plan to finance
Not sure

How often do you think about your hair loss?

Occasionally
Often
All the time

How did you find us?*

Explain ... Google search? Referral

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HIPAA AUTHORIZATION. To the extent information in this form is protected health information under the Health Insurance Portability and Accountability Act, as amended, and its regulations (“HIPAA”), I authorize the use and disclosure of such information in accordance with this HIPAA AUTHORIZATION. I authorize the use and disclosure of all of the information that I have entered into this form. I certify that I am the individual whose information is included in this form or I am the individual’s representative. The purpose of this disclosure is to allow communication of the patient information to OC Hair Restoration. The Information will be disclosed to OC Hair Restoration and/or its information technology contractors in order to facilitate communication between me and the medical practice. I understand that I have the right to revoke this Authorization at any time prior to my submission of this form by simply not signing this Authorization, but once I sign this Authorization and submit the form, the information will be disclosed to Recipients in reliance upon my Authorization. I understand that I am not required to sign this Authorization and that any medical practice making this form available on its website may not condition my treatment on whether I use this Secure Form to communicate with the medical practice. This Authorization has no expiration date. I understand that the Information used or disclosed pursuant to this Authorization may be subject to re-disclosure by the Recipients and will no longer be protected by HIPAA. I hereby acknowledge that I may print a copy of this Authorization for my records.

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Appointment Request Form