It is always best to have a personal one-on-one consultation with Dr. Wallik, so that he may evaluate you and offer specific recommendations. For those individuals who may have difficulty attending an hour long consultation, you may complete the form below for a Virtual Consult.

After reviewing your information and photos, Dr. Wallik will contact you by e-mail.

To schedule a free, in-person consultation click here.

Step 1: Simply fill in our secure online questionnaire below and upload your photos. Please NOTE: Fields marked with an * are required. -----------------------------------------------------------------------------------------
Personal
*First Name:
*Last Name:
*Email:
Phone:
Address:
City:
State/Province:
Zip:
Country:	- Please select - United States Afghanistan Albania Algeria American Samoa Andorra Angola Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil British Virgin Islands Brunei Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad Chile China Colombia Comoros Congo Costa Rica Cote D'ivoire Croatia Cuba Cyprus Czeck Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakstan Kenya Kiribati Korea, North Korea, South Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caldedonia New Zealand Nicaragua Niger Nigeria Niue Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierre Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka St. Helena St. Kitts and Nevis St. Lucia St. Pierre and Miquelon St. Vincent and the Grenadines Sudan Suriname Svalbard and Jan Mayan Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands Western Sahara Yemen, North Yemen, South Yugoslavia Zaire Zambia Zimbabwe
Age at which your hair loss began:
Date of Birth  (DD/MM/YY)
Gender	Male Female
Current Age
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Medical:
Medical history that might affect hair transplant surgery (such as skin diseases, allergies, medications, ongoing other illnesses):
Previous hair transplant procedures or other types of hair restoration surgery. Please indicate dates and type of procedure (if known):
Surgical history that might affect a hair transplant procedure (such as previous surgeries, history of keloids):
Hair loss medications: date started
Propecia - date started:
Rogaine - date started :
Other - date started:
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Photos to be uploaded:
Please send only the most representative photos. NOTE: PHOTOS MUST BE JPG FORMAT
A. Frontal view at forehead level
B. Left-sided view at forehead level
C. Right-sided view at forehead level
D. Frontal view from above directed down toward the forehead
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Other
How did you hear about us?
Comments: (Please include any additional information that you think would be helpful to the doctor.)
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Step 2
After reviewing your information and photos, Dr. Wallik will contact you by e-mail.