Returning Patient Form

Please do not use this form if you have an urgent medical problem or you need to reschedule an existing appointment. Instead, contact our office at (253) 572-2949. After you submit your request, our appointment scheduler will respond within 48 hours.

Returning Patient Form
In case of Emergency
Preferred Pharmacy
Health History
Lifestyle; do you currently/have you ever:
Current medications:
Current medications:
Allergies:
Do you have/have you ever been treated or evaluated for the following:
Before & After Photo Consent


Privacy and confidentiality is a sacred part of any patient’s journey. Northwest Hair Restoration fully enforces HIPAA laws (Health Insurance Portability and Accountability Act of 1996) to ensure proper handling of all medical records.


In our effort to educate other patients in the decision-making process, we request your consent to use your Before & After photos in various platforms outlined below. Under no circumstance is this a requirement; The option of allowing Northwest Hair Restoration (NWHR) to use your photos is completely voluntary and can be withdrawn any time at your request.

NOTE: All photos are cropped to highlight your hair and to obscure your face.

I grant permission for Northwest Hair Restoration to:
* = Input is required

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