Louis M. Iorio, MD
5 Professional Circle,
Suite 107,
Colts Neck, NJ 07722
Phone: (732) 780-9191
Fax: (732) 780-0961

1140 Burnt Tavern Rd, Suite 1E,
Brick, NJ 08724
Phone: (732) 458-7400

Hair Restoration Inquiry

Use this form to send your question to Dr. Iorio and to request a consultation. Please take a moment to fill out this background information so the doctor has the information he needs to answer you fully. This questionnaire does not take the place of an actual in person consultation. With the following information, Dr. Iorio can give you an informed reply.

*indicates a required field.

Name*
City*
State*
Email*
Phone
  Home Work Mobile
Age
Gender
Marital Status Single Engaged Married
Have you had surgical Hair Transplant in the past? Yes No
What term best describes your natural hair?
What is the natural color of your hair?
What is the texture of your hair?
At what age did you begin to notice hair loss?
Is there a family history of baldness? Yes No
Have you tried any of the following medical therapies? Propecia Yes No
  Rogaine Yes No
  Saw Palmetto Yes No
  Other Yes No
Have you had cosmetic surgery in the past? Yes No
Please indicate which image closest represents your hair loss condition when your hair is wet:
Please describe what you would like to achieve with this procedure (restore front hairline, mid scalp, back or your entire balding area). Also you can enter any additional questions for Dr. Iorio.
The best way to tell if you are a candidate for cosmetic surgery is to be evaluated in person by Dr. Iorio and his staff. Check here if you would like to be contacted to schedule a complimentary consultation in the doctor's office. Please include a daytime phone in the above form.