NeoGraft consent and patient screening form template

Key takeaways

This NeoGraft template is a two-page pre-procedure consent and screening form, not an operative record or a follow-up tracker.

It opens with a procedure description that covers risks, contraindications, and the basics of aftercare, so every patient reads the same information.

An informed consent and photography clause records that the patient understood the advice and agreed to clinical images being kept in their notes.

The screening section runs 11 yes or no questions on medical conditions, pregnancy, autoimmune and neuromuscular disease, allergies, infection, and medications.

Practice management software like Pabau sends the form before the visit and files the signed copy against the patient record.

NeoGraft is an automated follicular unit extraction (FUE) system used in hair restoration practices. It lifts individual follicles from the donor area with pneumatic pressure rather than a scalpel, so the patient is left with no linear strip scar.

The consultation that precedes the procedure carries most of the legal weight. It is where risk is explained, candidacy is questioned, and permission is given in writing. This template covers that stage.

The sections below cover what the form contains and how to run it through a consultation. They also name the records that have to sit alongside it. Every field described here is in the downloadable file.

What is inside the NeoGraft consent form?

The download is a two-page pre-procedure form. It has four parts, and they run in the order a consultation naturally follows.

• Procedure information: a plain description of automated FUE, followed by risks and side effects, contraindications, and short aftercare guidance. Risks named include swelling, bleeding, bruising, infection, folliculitis, scabbing, numbness, and shock loss.
• Informed consent and photography: a signed statement that the patient understood the aims, the risks, the alternatives, and the likelihood of success. It also authorizes clinical photographs and video to be kept with their medical records.
• Screening questions: 11 yes or no items. They confirm understanding and free consent. Then they screen for medical conditions, pregnancy or breastfeeding, neuromuscular disease, and autoimmune disease. The last items cover skin conditions, allergies and anaphylaxis, active infection at the site, and prescription medications.
• Open-text history boxes: five free-text fields. Two cover other medical or social history and the patient’s aims for the procedure. The rest ask about previous similar treatments, current concerns, and anything else the practice should know.

The form ends with a line confirming the patient will keep the information and refer back to it during treatment. That is the whole document.

What the form does not include

The boundary matters, because each missing piece still has to be recorded somewhere in the chart.

• No Norwood scale field or any other hair loss classification.
• No donor density measurement or graft count estimate.
• No procedure-day record for final graft numbers, extraction time, or a recipient site map.
• No milestone follow-up schedule and no dated photo checkpoints.

Those belong in your clinical notes and your operative record. The section on what to record alongside consent covers how practices usually handle them.

The panel below sets the form’s four parts against the four records it leaves to you.

How to run the form through a consultation

The form does its job across five steps, from the first inquiry to the signed copy in the chart.

1. Send it before the consultation. Patients answer the screening questions and write their history in their own time. Reading the risks at home beats skimming them in a waiting room with a pen in hand.
2. Review the answers before the patient arrives. A yes on autoimmune disease, active infection, pregnancy, or anticoagulant medication changes the conversation. Flag it and prepare your questions rather than discovering it mid-appointment.
3. Talk through the procedure information section together. Cover shock loss, variable graft survival, asymmetry, and the possibility of an unsatisfactory result. The open-text box on aims and desired outcome is where unrealistic expectations usually surface.
4. Take the signature and the photography permission on the day. Both sit in the same clause, so a patient who declines images should be recorded as declining rather than left blank.
5. File the completed form against the patient record. It needs to be retrievable years later, next to the baseline photographs and the operative note from the session it authorized.

Who the form is written for

Hair transplant practices, dermatology practices that offer restoration, and cosmetic surgery centers running FUE all need a consistent consent document. This one is written for the NeoGraft procedure specifically, so the risks match the technique.

Aesthetic groups that offer restoration alongside injectables and skin treatments carry a longer list of consent documents. They tend to keep those in one system, which is what medical spa software is built for.

Solo practitioners use it to keep their own consultations consistent from patient to patient. Multi-site groups use it so a patient in one location signs the same document as a patient in another.

It is also useful for new staff. A technician or coordinator running pre-consultation calls has a fixed list of questions to work through, which shortens training.

Why standardized consent matters for hair restoration

Hair restoration is elective and outcome-driven, so disappointment with the result is a common complaint. A signed record of what was explained is the practice’s clearest answer when a patient says the risks were never mentioned.

Standardization also removes variation between practitioners. Practices that move to structured digital consultation forms spend less time preparing for appointments. They also catch candidacy problems earlier, because the same questions get asked every time.

A second benefit is easy to overlook. A completed history form gives whoever performs the procedure a briefing they can read in a minute. That holds even if they did not run the consultation.

What to record alongside consent

Consent is one document in a longer chain. Three other records do the work this form does not, and each needs its own home in the chart.

• Candidacy assessment: hair loss pattern and stage, donor area density, hair characteristics, and the graft count you estimate from them. This is what justifies the treatment plan you quoted.
• Operative record: the final graft count, extraction and implantation time, the recipient areas treated, medications given, and any change you made during the session.
• Aftercare and follow-up: the written instructions the patient leaves with, plus the review points you work to. Many practices check in at one week, four weeks, then three, six, and twelve months.

Timelines are worth stating plainly at consultation. Transplanted hair commonly sheds in the first weeks after the procedure. New growth usually starts at three to four months, and the final result is typically judged at nine to twelve months.

Standardized photographs make that conversation concrete. Take a baseline set at consultation, then further sets at six and twelve months. Kept in before-and-after photo software, they give you an objective record of density.

Storing signed forms and staying compliant

Consent forms, medical histories, and clinical images are all protected health information. Under HIPAA they need controlled access, an audit trail, and secure storage, which rules out a shared drive or a folder of phone photos.

The photography clause deserves attention of its own. It authorizes images as part of the medical record, so separate permission should be sought before any of them appear in marketing.

Device-related problems should also be logged. Serious injuries or malfunctions involving the NeoGraft system can be reported to the manufacturer and to the FDA through MedWatch. Your internal note should record what happened and when.

Retention rules vary by state, so check the period that applies to you and keep the signed form for at least that long. Our guide to hair transplant compliance covers the wider record-keeping picture.

How Pabau turns the NeoGraft consent form into a live workflow

A PDF is static. It has to be printed, handed over, scanned, and filed. Every one of those steps is a chance for a form to go missing before the procedure date.

Practice management software like Pabau rebuilds the same document as a digital form. The patient completes it on their phone before the appointment and signs on screen. The answers land in their record rather than in a filing cabinet.

From there the rest of the chain joins up. Automated workflows chase an unsigned form and book the follow-up points you work to. They also send the reminder that gets the patient back at six and twelve months for photographs.

The result is fewer procedure days delayed by paperwork. It also means a complete record when a question comes up years later, and a follow-up schedule nobody has to chase by hand.

See how Pabau supports hair restoration practices

Send NeoGraft consent forms before the appointment, capture signatures digitally, and keep screening answers, photographs, and follow-ups in one patient record.

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Conclusion

Use this template for what it is. It is a strong pre-procedure consent and screening form, and it will not track a patient through the twelve months that follow.

Practices that treat it as the first link in a chain get the most from it. Pair it with a candidacy assessment, an operative record, a written aftercare sheet, and dated photographs, and the patient file holds up under scrutiny.

The trade-off is administrative. Each of those records is another document to chase on paper, which is why growing practices move the chain into one system. Book a demo to see how Pabau keeps NeoGraft consent, photographs, and follow-ups in a single patient record.

Continue your research

Need the candidacy record this form does not carry? Scalp regions explained maps the donor zones and layers you assess before quoting a graft count.

Working out how long to keep signed forms? Compliance for hair transplant clinics covers retention periods, consent records, and patient data handling.

Chasing forms and photographs by hand? Best hair transplant clinic software in the US compares the systems that store consent against the patient record.

Setting expectations before the consultation? Hair transplant clinic marketing covers how to talk about timelines and outcomes before a patient books.

Frequently asked questions