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Have an account?

Client Intake Form

Date of Birth
Month
Day
Year
Multi-line address

Finance information (Optional)

How did you hear about us?

Please use the following scale to categorize your level of male pattern hair loss:

What is your Norwood Scale?

All payments, booking fees, and deposits made to book our services are non-refundable.


The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to A Micro & Co/Scalp Micro Pro Clinic. I understand that I am financially responsible for any balance. I also authorize A Micro & Co or Finance Company to release any information required to process my application.

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