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Virtual Consultation

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We are a ISHRS Verified COVID-Protected Facility

While the Internet is a great place to get basic information about hair restoration procedures, it does not compare to a personal, in-depth consultation with Dr. Roy Stoller, who is here to guide you through all the steps of an informed decision-making process and to map out a treatment plan that fits your needs and goals.

We invite you to schedule a consultation today by calling us at (212) 920-4499 or by filling out the brief 4-step form below. You will be contacted as soon as possible.

The information you provide will never leave our office. The information sent will be 100% confidential and discreet.

This form is 4 steps: 1. Your Information / 2. Hair Loss History / 3. Hair Loss Image Upload / 4. HIPPA Consent

  • Your Information

    The information you provide will never leave our office. The information sent will be 100% confidential and discreet.
  • Hair Loss History

  • 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.

    Once we receive your photos, we will set up an appointment with Dr. Stoller to speak with you directly.

  • Example - Top of Head

  • Max. file size: 256 MB.
  • Example - Front of Head

  • Max. file size: 256 MB.
  • Example - Right Side of Head

  • Max. file size: 256 MB.
  • Example - Crown of Head

  • Max. file size: 256 MB.
  • Example - Back of Head

  • Max. file size: 256 MB.
  • HIPAA Information and Payment Policy Consent Form

  • The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your policy. Implementation of HIPAA requirements officially began on April 14th 2003. Many of the policies have been our practice for years. This form is a “friendly” version. Amore complete text is posted in office.

    What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services, www.hhs.gov

    We have adopted the following policies:

    1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, Health insurance payers as are necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient's condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.

    2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, email, U.S. mail, or by any means convenient for the practice and or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you may find valuable or informative.

    3. The practice utilizes a number of vendors in conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.

    4. You understand and agree to inspections of the office and review of documents, which may include PHI by government agencies or insurance payers in normal performance of their duties.

    5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or doctor.

    6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods, or services.

    7. We agree to provide patients with access to their records in accordance with state and federal laws.

    8. We may change, add, delete or modify any of these provisions to better serve the needs of both the practice and the patient.

    9. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform your request.

    I do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA Information Form and any subsequent changes of office policy. I understand that this consent shall remain in force from this time forward.