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Suitability Assessment
This will provide us with sufficient information to assess your suitability for a consultation and treatment.
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1
Areas of Concern
Please select which area(s) are concerning you
Hairline/Frontal
Temples
Mid-zone
Crown/Vertex
Other
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2
Full Name
*
This field is required.
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3
Gender
*
This field is required.
Please Select
Male
Female
Other
Please Select
Please Select
Male
Female
Other
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4
Date of Birth
*
This field is required.
-
Day
Month
Year
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5
Phone Number
*
This field is required.
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6
E-mail Address
*
This field is required.
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7
Extent of Hair Loss
*
This field is required.
Use the Scale below to select the extent of hair loss which resembles you most
Grade 1
Grade 2
Grade 3
Grade 3 Vertex
Grade 4
Grade 5
Grade 6
Grade 7
Female Pattern Loss
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8
Upload a Picture of Your Hairline
*
This field is required.
Please take a clear picture showing your hairline ensuring that any recession is not covered
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
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9
Upload a Picture of Your Left Side
*
This field is required.
Please take a clear picture showing your left side ensuring that any hair loss is not covered
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
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10
Upload a Picture of Your Right Side
*
This field is required.
Please take a clear picture showing your right side ensuring that any hair loss is not covered
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
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11
Upload a Picture from above
*
This field is required.
Please take a clear picture showing your hair loss from above area ensuring that any hair loss is not covered
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
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12
Upload a Picture of the back of your head (donor area)
*
This field is required.
Please take a clear picture showing your donor area
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
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13
Please provide a brief history of your hair loss and any further details
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14
Preferred Clinic Location
for Consultation/Treatment
London
Leeds
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15
Tags
Todo
In Progress
Done
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