770.649.0094
4343 Shallowford Rd #150, Marietta,GA 30062
VIRTUAL CONSULT
TEXT US
Home Page
About Dr. Kelley
Weight Loss
Weight Management program GLP1
Lean Body Program
Wellness
Bioidentical Hormones
IV Therapy
Liquivida Drip Glossary
GI Health
Oshot l Feminine Rejuv
O Shot
Vampire winglift
V fit Gold
Procedures
Xeomin Wrinkle relaxer
Botox
Sculptra-CWA Precise Sculpt
Wrinkle Fillers- Contour and Rejuvenate
Radiesse-Contour, Lift and Tighten
Microneedling for beautiful and healthy skin
Exilis Elite Facial Skin Tightening
PRP Hair Therapy
Pre and Post PRP hair Instructions
PRP Injections
O Shot
Testimonials
Pricing
770.649.0094
4343 Shallowford Rd #150, Marietta,GA 30062
VIRTUAL CONSULT
TEXT US
Home Page
About Dr. Kelley
Weight Loss
Weight Management program GLP1
Lean Body Program
Wellness
Bioidentical Hormones
IV Therapy
Liquivida Drip Glossary
GI Health
Oshot l Feminine Rejuv
O Shot
Vampire winglift
V fit Gold
Procedures
Xeomin Wrinkle relaxer
Botox
Sculptra-CWA Precise Sculpt
Wrinkle Fillers- Contour and Rejuvenate
Radiesse-Contour, Lift and Tighten
Microneedling for beautiful and healthy skin
Exilis Elite Facial Skin Tightening
PRP Hair Therapy
Pre and Post PRP hair Instructions
PRP Injections
O Shot
Testimonials
Pricing
Home Page
About Dr. Kelley
Weight Loss
Weight Management program GLP1
Lean Body Program
Wellness
Bioidentical Hormones
IV Therapy
Liquivida Drip Glossary
GI Health
Oshot l Feminine Rejuv
O Shot
Vampire winglift
V fit Gold
Procedures
Xeomin Wrinkle relaxer
Botox
Sculptra-CWA Precise Sculpt
Wrinkle Fillers- Contour and Rejuvenate
Radiesse-Contour, Lift and Tighten
Microneedling for beautiful and healthy skin
Exilis Elite Facial Skin Tightening
PRP Hair Therapy
Pre and Post PRP hair Instructions
PRP Injections
O Shot
Testimonials
Pricing
Hair loss history
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Hair loss history
Hair History. Please text pictures to 770-649-0094.
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Phone for emergency
How did you hear about our office?
General Medical Heath Questions:
Please list any medications that you are taking
Are you taking any aspirin products or blood thinners?
Yes
No
Do you have any drug allergies? If so, please list them.
Please list any surgeries/operations.
List any Supplements you are taking.
Please place an X if you have ever had any of these conditions
Fever blisters
Heart trouble
High blood pressure
Asthma
Diabetes
Thyroid problems
Bleeding tendency
Excessive scarring or abnormal healing
Easy bruising
Autoimmune illness like Lupus
Do you smoke cigarettes?
Yes
No
If yes, how many a day?
Do you drink alcohol?
Yes
No
Hair loss Questions
How long have you had hair loss? What you have tried?
Does hair loss run in your family?
Yes
No
Is your hair loss the typical pattern loss with a receding hairline and/or thinning crown?
Yes
No
Do you have diffuse thinning of your hair?
Yes
No
Do you think your hair loss is related to hormones?
Yes
No
Have you had recent labwork?
Yes
No
FEMALES- Have you been through menopause?
Yes
No
MALES ONLY Are you currently on testosterone?
Yes
No
Have you worn wigs?
Yes
No
Have you ever had a hair weave?
Yes
No
Have you ever had hair extensions?
Yes
No
Do you wear your hair in a ponytail or any other high traction style?
Yes
No
Do you wear your hair in braids, cornrows or have dreadlocks?
Yes
No
Confirmation
Do you affirm that you have answered all questions truthfully and to the best of your knowledge?
*
Yes
