Online Consultation
Thank you for participating in our virtual consultation! Please answer the following questions and upload photos. We will get back to you within 2 business days.
First & Last Name *
Phone Number *
E-mail *
How did you hear about us? *
In order of importance, list the areas of the face or head that are a concern to you or that you are unhappy with. Please number each item with one being the item you are most concerned with. *
Uploading Photos
For all pictures, we have a few guidelines to help guarantee that we can give you the best consultation possible.

1) Do not wear make-up.
2) Take pictures against a solid background and with good lighting. Black backgrounds are best, but white will work as well. No patterns or shadows in the background.
3) Have someone else take the pictures for you. Selfies tend to not turn out well.
4) If you are wanting a facial assessment, pull the hair back to assure that your forehead is exposed entirely. (If you are doing a hair-loss consultation, style the hair in a way that shows your problem areas)

Cosmetic:
#1 Relaxed Headshot
#2 Smiling Headshot

Hair Loss/Thinning:
#1 Relaxed Headshot
#2 Top of Head
#3 Back of Head

Cosmetic Photo Upload
Hair Loss/Thinning Photo Upload
While we take every effort to maintain privacy, communications through our website or via email are not necessarily encrypted and/or secure. Use of the internet or email is for your convenience only, and by using them, you assume the risk of unauthorized use.By checking this box you hereby agree to hold Mountain West Medical Services, its providers, and affiliates, harmless from any hacking or any other unauthorized use of your personal information by outside parties. *
Required
Mountain West Medical wants to thank you for participating in this online virtual consultation. We will have a response to you within 2 business days. Please contact us with any further questions or concerns at Info@mountainwestmedical.com or 208-229-8739.
Submit
Never submit passwords through Google Forms.
This form was created inside of mountainwestmedical.com. - Terms of Service