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Online Consultation Form

Please fill out the following hair loss assessment form.

Your Hair Loss Evaluation

1.Your Age:
Gender:
2. Your natural hair colour is?
 Black / Dark Brown Gray
 Med Brown Light Brown / Blond / Red
3. Which best describes the texture of your hair?
 straight wavy
 curly
4. What is the texture of your hair?
 fine medium
 thick
5. Click on the image that matches your hair loss condition when your hair is wet.

6. You noticed your hair loss at what age?
 < 20 20-30 31-40
 41-50 > 50
7. What are your expectations from hair transplantation (restore the front hairline, mid scalp, back, or your entire balding area)?
8. Have you consulted with a doctor about your hair loss condition?
 Yes
 No
With Whom?
9. Were you recommended any treatment for your hair loss?
10. Have you had a hair procedure before?
If so with whom?
 Yes
 No
11. Have you used any of these oral & topical medications for your hair loss?
Rogaine
 Past
 Present
Saw Palmetto
 Past
 Present
Propecia
 Past
 Present
Other
 Past
 Present
12. Has your hair loss had an affect on your life, if so in what way?
Feel free to send your comments or questions:
13. Upload an image:

(jpg, gif or png only - 5Mb max size)

Your Contact Information

First Name:(*)
Last Name:(*)
Check here if you do NOT want any information mailed to your Street address.
 No Mail to address
Street Address Line 1:(*)
Street Address Line 2:(*)
City:(*)
State/Province:(*)
Post Code:(*)
Country:(*)
Day Phone:
Evening Phone:
-  Please call me by phone Check this if you wish to be called
Email Address:(*)
I want to be on the private newsletter list.
 Yes
I prefer to be contacted by:
 email phone either
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Or call us now on: 1800 689 939