Virtual Follow-Up

Name*

First Last

Gender (assigned at birth)*

Please enter your birthday*

Did you have surgery?*

If you had surgery, what month and year?

Are you using any of the following?*

Do you have any questions or concerns you would like to address with Dr. Stoller?

Hair Loss Image Upload

Please attach five photos: top, front, right, crown and back of your head. Your face should take up 75% of the photo.

Example - Top of Head

Top of Head Image Upload

Max. file size: 256 MB.

Example - Front of Head

Front of Head Image Upload

Max. file size: 256 MB.

Example - Right Side of Head

Right Side of Head Image Upload

Max. file size: 256 MB.

Example - Crown of Head

Crown of Head Image Upload

Max. file size: 256 MB.

Example - Back of Head

Back of Head Image Upload

Max. file size: 256 MB.