Office Consultation Form In order to request your Consultation with Dr. Boden please complete the Patient Intake Form below. Please call (860) 563-1400 with any questions. "*" indicates required fields LinkedInThis field is for validation purposes and should be left unchanged.Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Cell Phone*Email* Date of Birth* Age*Please enter a number from 18 to 90.Preferred Consultation Date* Preferred Consult Time* Hours : Minutes AM PM AM/PM Referred by*SelectGoogleSocial MediaPhysicianFriendOtherPreferred Pharmacy*When did you first notice your hair loss?Where is your hair loss most bothersome?*What first made you aware of your hair loss?What bothers you most about your hair loss?*What concerns do you have about hair transplant surgery?* Pain Scarring Cost Doesn't look natural Other Select all that applyWhat other hair loss options did you try?* Propecia Laser Hair Therapy Supplements Hair Products Rogaine PRP Hair System Previous Hair transplant Surgery Select all that applyAre you willing to go bald or shave your head?* Yes No Not sure What would be the best thing about having your hair back?* I'd look younger I'd feel more attractive I'd feel more confident I could style my hair the way I want? Select all that applyAdditional Questions and CommentsConsent* I acknowledge that HIPAA Privacy Practices have been made available to me and I understand that all medical information will be kept confidentialPhoto UploadsYou can upload photos of your hair loss to help us be better prepared for your consultation.Photo - Front ViewMax. file size: 50 MB. Photo - Left side ViewMax. file size: 50 MB. Photo - Right Side ViewMax. file size: 50 MB. Photo - Top Rear ViewMax. file size: 50 MB. Consent I consent to receive non-marketing text messages and calls from Scott Boden MD LLC DBA Hair Restoration Center of Connecticut regarding appointment reminders, and service updates. Message frequency varies, message & data rates may apply. Reply HELP for assistance, reply STOP to opt out. I consent to receive marketing text messages and calls from Scott Boden MD LLC DBA Hair Restoration Center of Connecticut regarding promotional offers, new services, discounts, and marketing. Consent is not a condition of purchase. Message frequency varies, message & data rates may apply. Reply HELP for assistance, reply STOP to opt out. Δ Photo Upload Angles
