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Home
Hair Transplant
PRP Treatment
Online Consultation
Gallery
Price
Contact

Request a Free Consultation

(Your data will not be published)

Consultation For Men

Basic Information
Hair Loss History
Images
Contact Details

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Age :

Hair Color :

Skin to hair color :

Hair Description :

Hair Texture :

Please select the picture that best resembles your current hair loss :

At what age did you begin to notice hair loss ?

Are you still losing hair ?

Yes No

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

Please indicate when your hair loss affects:

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

Have you ever had a hair transplantation consultation?

Yes No

Have you ever had a hair transplantation?

Yes No

Front :

Left Side :

Right Side :

Top :

Donor Area :

* Required fields

images

images

images

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Disclaimer:

The results of surgical and other procedures may vary from patients to patients. Whilst all our treatments
are carried out professionally providing highest ethical standard and consistent quality care to all our
patients, permanent results cannot be guaranteed.

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