Office Consultation Form

In order to request your Virtual Consultation with Dr. Boden please complete the form below. Please call (860) 563-1400 with any questions.

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cell Phone*
Email*
Date of Birth*
MM slash DD slash YYYY
Age*
Please enter a number from 18 to 90.
Preferred Consultation Date*
MM slash DD slash YYYY
Preferred Consult Time*

: Hours

Minutes

AM/PM
Referred by*
Preferred Pharmacy*
When did you first notice your hair loss?
Where is your hair loss most bothersome?*
What first made you aware of your hair loss?
What bothers you most about your hair loss?*
What concerns do you have about hair transplant surgery?*
- Pain
- Scarring
- Cost
- Doesn't look natural
- Other
Select all that apply
What other hair loss options did you try?*
- Propecia
- Laser Hair Therapy
- Supplements
- Hair Products
- Rogaine
- PRP
- Hair System
- Previous Hair transplant Surgery
Select all that apply
Are you willing to go bald or shave your head?*
- Yes
- No
- Not sure
What would be the best thing about having your hair back?*
- I'd look younger
- I'd feel more attractive
- I'd feel more confident
- I could style my hair the way I want?
Select all that apply
Additional Questions and Comments
Consent*
I acknowledge that HIPAA Privacy Practices have been made available to me and I understand that all medical information will be kept confidential
Photo Uploads
You can upload photos of your hair loss to help us be better prepared for your consultation.
Photo - Front View
Max. file size: 50 MB.
Photo - Left side View
Max. file size: 50 MB.
Photo - Right Side View
Max. file size: 50 MB.
Photo - Top Rear View
Max. file size: 50 MB.
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HAIR RESTORATION CENTER OF CONNECTICUT

At the Hair Restoration Center of Connecticut, Dr. Scott Boden believes that no one needs to suffer from hair loss. With today’s ultra-refined hair transplantation techniques you can have fuller hair and have a natural hair line that is indistinguishable from the one you were born with.

The Only Recognized Hair Transplant Surgery Certification Worldwide

Appointment Request

Please call 860-563-1400 or submit the form below and a representative will contact you to answer your questions and schedule a comprehensive consultation.

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Phone*
Email*
What are you interested in?*
What is your desired time frame?
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HAIR RESTORATION CENTER OF CONNECTICUT

Appointment Request