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.
General Information

The information you submit will be kept confidential and will only be used to provide a hair loss assessment.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of birth*

DayMonthYear
Email*
Phone Number*

Country CodePhone Number
What gender do you identify as?*
What are you preferred pronouns?*
i.e. he/him, she/her, they/them, etc.
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.
Please describe the thinning areas that concern you (in priority of order).*
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 on the frontal area only?*

YesNo
If no, please provide details below.*
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.
Are you currently taking any medication?*

YesNo
If yes, please provide information below.*
Do you have any pre-existing medical conditions?*
Which treatment(s) are you interested in? Please select all that apply.*

Surgical treatment (hair transplant or repair surgery)Non-surgical treatment (hair loss medication, laser helmet, PRP, etc.)PRP treatment only
What is your ideal timescale for undertaking your treatment?*
How did you hear about The Maitland Clinic?*
Additional information: Is there anything else you think our team should know about?
Photographs

It would be very helpful if you could attach some photographs of the areas of concern.
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:

Online Consultation Form

General Information

Hair Loss History

Photographs