• Online Consultation Form

  • Please take a moment to complete this short form so that we can assess your hair loss and advise on options. The information you submit will be kept confidential and will only be used to provide a hair loss assessment. For more information, please visit our Privacy Policy page.

  • General information

  • Submission date
     - -
    2 digit day, 2 digit month, 4 digit year
  • Submission date and time
  • Date of birth*
     - -
    2 digit day, 2 digit month, 4 digit year
  •  -
  • What gender do you identify with?*
  • What are you preferred pronouns?

  • Hair loss history

  • Please provide as much detail as possible. We are only able to provide advice based on the information given.

  • Have you ever undergone a hair transplant procedure?*

  • To help us assess your case, please provide the following photos:

    • Photos of your hair prior to your hair transplant
    • Photos immediately after your hair transplant (to show graft placement)

    Please note: you can upload multiple photos at a time.

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  • Your enquiry

  • Which treatment(s) are you interested in?*
  • Due to the limitations of donor hair supply, full coverage of the crown area for many patients is not possible. Would you be happy for partial coverage, focusing only on the frontal half of the scalp?*

  • Hair loss can continue to progress after a hair transplant. For younger patients, or patients whose hair loss is not yet stable, Dr Ball may recommend medical treatment or an assessment with a trichologist before considering surgery. This helps us plan a natural-looking result that will continue to look appropriate in the future.

  • Do you have any pre-existing medical conditions?*

  • Please note that certain medical conditions may limit your suitability of some treatments. Therefore, it is essential for us to carefully review your medical history prior to making any recommendations.

  • Have you ever suffered from keloid scarring? (Keloid scars are firm, raised scars that grow beyond the edges of the original wound.)*
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  • Are you currently taking any medication, including blood thinners (i.e. aspirin, apixaban, rivaroxaban, warfarin etc.)?*
  • Do you have a history of cardiac arrhythmia/irregular heartbeat?*
  • How did you hear about The Maitland Clinic?*
  • I give permission for The Maitland Clinic to contact me by text or email to inform me of any new developments or hair loss treatment products that may become available in the future.*

  • Photographs

  • It would be very helpful if you could attach some photographs of the areas of concern. We would kindly ask that you only send photos with dry hair.

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