Hair Transplant Medical Form – CSTAR International

914-340-1155

CSTAR Connect Membership Portal

Surgical Coordination Services
Join CSTAR Connect
Shop
Patient Medical Forms
Search Doctors

Hair Transplant Medical Form

If you are human, leave this field blank.

PATIENT MEDICAL FORM

First Name *

Last Name *

Email *

Phone *

Address *

Apt, suite, etc.

Country

City

State

Zip code

Date of Birth *

Gender *

Preferred Surgery Date

List the procedures you want to have done:

PATIENT MEDICAL INFORMATION

Age *

Weight *

Height in inches *

BMI (Body Max Index) *

Do You Smoke? *

Are you taking any pills, or drugs? *

If yes, which ones? Please explain:

Current Medications and Dosage

Do you have any food allergies?:

Have you ever been treated for depression?

Do you have any drug allergies?:

FAMILY MEDICAL HISTORY

Please indicate if you have any of the following:

Diabetes

Hight Blood Pressure

Heart Failure

Heart Attack

Chest Pain/Angina

Hight Cholesterol

GERD/Heartburn

Cancer

Asthma/COPD

Lung Problems

Arthritis

Liver Disease/Hepatitis

Crohn\'s Disease/Colitis

AIDS/HIV

Sicklemia / Sickle Cell Trait

Lupus

Sleep Apnea

Joint Pain/Back Pain

Ulcers

Anemia

Bleeding Problems

HepB / HepC

Thyroid

None of the above

Please indicate any of the following: *

Heart Disease

Diabetes

Hypertension

Asthma

Cancer

None

Not Known

PREVIOUS SURGERIES

Procedure(s)

Please list all procedures

Year of Procedure

WOMEN

Birth control pills, hormone replacement medications, hormone patch or implant *

Are you pregnant now? *

Planning for more pregnancies *

UPLOAD IMAGES

Submit Photos

Photos are submitted directly to the surgeons for evaluation and feedback. Please see our Picture Submission Guidelines. Please Note: No virtual consultation can be scheduled without photos.

Image 1 *

Image 2 *

Image 3 *

Image 4 *

Image 5

Image 6

Follow Us

Company

Home
Our Services
About
Articles
Media
CSTAR Events

Support

Contact
Patient Forms
Refund & Cancellation Policy
Email Signup
Terms and Conditions
Privacy Policy
Medical Tourism Coverage

More Info

Join CSTAR Connect
Shop
Surgery & Wellness Tours
Pre & Post Surgical Vitamins
Search Provider Directory
Subscribe to our Magazine

Membership Login Portal
My Account
Refund Policy

© 2017-2021 CSTAR International. All Rights Reserved.