Appointment Request Form

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
No

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?

Yes
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

Comments (optional) Note: 500 character limit.

NOTICE: HIPAA AUTHORIZATION REQUIRED TO USE THIS FORM. SIGNATURE FIELD BELOW.

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.

TYPE YOUR FULL NAME BELOW AS SIGNATURE AND AUTHORIZATION*

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