1.Basic Information2.History3.Contact Details4.Image5.Complete* Denotes A Required FieldTell us some basic information about your current hair loss. Age* : Hair Color: Select Hair ColorBlackDark BrownLight BrownSalt & PepperRedBlondeGrayOther Skin to hair color: Select Skin to hair colordark skin to light hair (high contrast)fair skin to dark hair (high contrast)medium skin to light hair (medium contrast)medium skin to dark hair (medium contrast)dark skin to dark hair (low contrast)fair skin to light hair (low contrast) Hair Description: Select Hair DescriptionCurlyWavyStraightOther Hair Texture: Select Hair TextureCoarseMediumFineOther Current Stage of Baldness: Select HereNone shownIIIII AIIIIII VertexIII AIVVIV AVIVIIV A 1.Basic Information2.History3.Contact Details4.Image5.Complete* Denotes A Required FieldYour Hair Loss History. At what age did you begin to notice hair loss ? Are you still losing hair?* Select HereYesNo If "no", for how long has your hair loss pattern stabilised?Describe your family history of hair loss (select all that has suffered from thinning and balding): Mother Father Brothers Grandfathers Uncles What treatment options have you already explored (select all that apply): Hair Transplantation Hair System (Toupee) Herbal remedies Laser Hair Therapy Mesotherapy Pigmentation Rogaine Propecia Other If "others", please give details:Please indicate in which areas your hair loss affects you: When I see pictures or videos At the beach or swimming When I get dressed up When I have to wear a hat My self-esteem In my social life When I see old friends It doesn't bother me What would you like to achieve with hair transplantation (restore the front hairline, mid scalp, back, or your entire balding area)?Have you ever had a hair transplantation consultation?* Select HereYesNo Have you ever had a hair transplantation?* Select HereYesNo If "yes", please give detailsPlease describe your current medical condition and current medications if any1.Basic Information2.History3.Contact Details4.Image5.Complete* Denotes A Required FieldYour Contact Details First Name*:Last Name*:Email*:Street Address Line 1: Street Address Line 2: City: Postal Code: Phone*:Mobile: Preferred Clinic*: Select HereSydneyFlorianopolisRio de JaneiroSao PauloVina Del MarParisDublinBarcelonaMadridMalagaDubaiAberdeenBelfastBirminghamBristolEdinburghGlasgowLeedsLondonManchesterMiami How did you hear about us?*: Select HereGoogleOther Internet SearchMagazineNewspaperReferralRadioTelevisionYellow PagesDermatologistGP RecommendationUnknown Please Select Your Procedure(s) of Interest*: Hair Transplant Scalp Pigmentation (MSP) Medical Treatment Other / Not Sure1.Basic Information2.History3.Contact Details4.Image5.CompleteUpload Your Hair Loss PhotosPlease upload some photographic evidence of your hair loss. Please Follow the type of images below:Acceptable formats are JPEG, GIF, PNG, and under 1 MB:Front:Left Side:Right Side:Top:Donor Area:*** Please Be Patient Whilst Your Images Upload. Once you click the Submit Button, the image upload and consultation submission will begin. Navigating from the site before the upload is finished will cancel the form submission. When everything is uploaded, you will be notified that it has been sucessful.
