How did you hear about Aloha Hair Replacement Center?
Do you have now or have you ever had any of the diseases and conditions below (if yes please check box)
Do you have any allergies to food or medicine? If so, please list:
Do you currently use any Prophylactic antibiotics
Are you currently taking any medications?
Are you taking any vitamins or herbal supplements?
Please List any vitamins or supplements:
Are you taking any over the counter medications?
Do you currently use IV drugs?
Which kind and in what frequency:
Have you ever had a blood transfusion?
Have you ever been exposed to HIV/AIDS?
Are you allergic to latex?
Do cuts on your skin heal with normal scars?
Please list any other disease or condition we should be aware of:
Please list any surguries you've had including cosmetic procedures:
Do you have artificial joints, pins or screws?
Do you require antibiotics prior to surgery?
Have you had a hysterectomy?
Have you experienced menapause?
I hereby authorize consent to submit this form to Aloha Hair Replacement Center prior to my consultation. Please sign your FULL NAME below:
