1.Basic Information 2.History 3.Contact Details 4.Image 5.Complete * Denotes A Required Field Tell us some basic information about your current hair loss. Age* : Hair Color: Select Hair Color Black Dark Brown Light Brown Salt & Pepper Red Blonde Gray Other Skin to hair color: Select Skin to hair color dark 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 Description Curly Wavy Straight Other Hair Texture: Select Hair Texture Coarse Medium Fine Other Current Stage of Baldness: Select Here None shown I II II A III III Vertex III A IV V IV A VI VII V A 1.Basic Information 2.History 3.Contact Details 4.Image 5.Complete * Denotes A Required Field Your Hair Loss History. At what age did you begin to notice hair loss ? Are you still losing hair?* Select Here Yes No 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 Here Yes No Have you ever had a hair transplantation?* Select Here Yes No If "yes", please give details Please describe your current medical condition and current medications if any 1.Basic Information 2.History 3.Contact Details 4.Image 5.Complete * Denotes A Required Field Your Contact Details First Name*: Last Name*: Email*: Street Address Line 1: Street Address Line 2: City: Postal Code: Phone*: Mobile: Preferred Clinic*: Select Here Sydney Florianopolis Rio de Janeiro Sao Paulo Vina Del Mar Paris Dublin Barcelona Madrid Malaga Dubai Aberdeen Belfast Birmingham Bristol Edinburgh Glasgow Leeds London Manchester Miami How did you hear about us?*: Select Here Google Other Internet Search Magazine Newspaper Referral Radio Television Yellow Pages Dermatologist GP Recommendation Unknown Please Select Your Procedure(s) of Interest*: Hair Transplant Scalp Pigmentation (MSP) Medical Treatment Other / Not Sure 1.Basic Information 2.History 3.Contact Details 4.Image 5.Complete Upload Your Hair Loss Photos Please 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.
