Online Consultation Form - The Maitland Clinic

  • 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

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  • 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 had a hair transplant?*

  • Your enquiry

  • Which treatment(s) are you interested in? Please select all that apply.*
  • 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?*

  • At The Maitland Clinic it is not our policy to perform surgery on young patients to restore a strong hairline that may look inappropriate in the future. Many patients who are losing hair and have not tried non-surgical treatments will be advised to see a trichologist to discuss ways to stabilise and improve their hair before surgery is considered.

  • 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.)*
  • 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?*

  • 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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