Online Consultation Form

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.

Hair loss history
Please provide as much detail as possible. We are only able to provide advice based on the information given.
When did you first notice your hair loss?*
Is your hair loss still progressing? (i.e. Are you likely to continue to lose hair after having a hair transplant?)*
Do you have a family history of hair loss? Please give details.*
Are you currently using Propecia/finasteride and/or Regaine/minoxidil? If so, how long have you been using each of these?*
What other hair loss treatments have you tried/are currently using?*
Have you ever had a hair transplant?*

YesNo
If "Yes", please provide details of each surgery.

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.
1) Front view (facing the camera with hair combed back)*

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2) Right and left view (with hair combed back)*

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3) Top view (taken from the front, while you look down, placing your chin on your chest)*

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4) Back/donor area (taken from behind)*

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Submission date and time
Should be Empty:

General information