Online Consultation Thank you for your interest in Arocha Hair Restoration. Please take your time filling out the consultation form below. The more information we have, the more accurate and comprehensive your personal Arocha Hair Restoration assessment will be. Name* First Last Phone*Best time to call?* Email* Age*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Have you ever had hair transplant surgery before? Yes No Which procedure did you have? FUE FUT Both How many grafts did you have transplanted? Which clinic performed your procedure? Have you used Propecia, Proscar or generic Finasteride? Never Used Used in the past Currently using as prescribed Have you used Rogaine / Regaine / Minoxidil? Never Used Used in the past Currently using Which procedure are you most interested in for your hair restoration? FUT FUE Tell us your hair loss story:Describe your restoration goalsApproximate date you would like to have your procedure with Dr. Arocha? MM slash DD slash YYYY Post ImageAccepted file types: jpg, jpeg, png, gif.Photo Instructions Ensure the room is evenly lit and bright. This is best accomplished in the daytime using natural light. 1. Do not use a flash. It obscures the scalp. If you think you need a flash, you need a brighter room. 2. Take several photos for each angle we request. Pick the photo from each set that has the best focus and clarity and best represents what you feel is the reality of your condition. 3. Place the camera slightly higher than your scalp, not at the same height. 4. Make sure that the photos show the loss that you are concerned about. Pull your hair back if your normal style hides the recession or loss. 5. When you have selected each of the six photos we require, upload each photo below. 6 . When the photos have completed being uploaded, click “submit” at the bottom of the page and wait for confirmation that the form has been sent. Do not go to another page before the submission is complete or else we will not receive your request. Please make images 6mb or less Allow us 24 to 48 business hours to reply with your personal hair restoration assessment prepared for you by Dr. Arocha.Optional Extra PhotoAccepted file types: jpg, jpeg, png, gif.Upload extra photo that helps to identify specific loss issues. For instance, if your hairstyle hides your hairline recession, include a photo with your hair pulled back.