Consultation Form

Submission date and time
Initial enquiry

Please take a moment to fill out this short form so we may assess your hair loss.
Name

First nameLast name
Email
Phone number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of birth

DayMonthYear
What gender do you identify as?
What are your preferred pronouns (i.e. he/him, she/her, they/them etc.)?
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 in the past?
Have you ever had a hair transplant?
If yes, please provide details of each surgery.
Please describe the thinning areas that concern you (in priority order).
Please describe how your hair loss affects you psychologically (e.g. mood, self-confidence, self esteem, anxiety etc).
Please describe how your hair loss affects you functionally (e.g. avoidance behaviour, social interactions, work, time spent styling, sport etc.).
What are you hoping to achieve from hair restoration treatment?
Are you aware that some people require more than one hair transplant to complete their goals?
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 our trichologist to discuss ways to stabilise and improve their hair before surgery is considered.
Are you currently taking any medication?
Do you have any pre-existing medical conditions?
Are you looking for surgical or non-surgical treatments?
Are you specifically interested in Platelet-Rich Plasma (PRP) treatment?
Do you have a timescale for treatment?
What would be your preferred form of consultation?
How did you hear about The Maitland Clinic?
Which venue are you able to attend for a consultation?
Additional information: Is there anything else you think our team should know?
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 (taken from behind)

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Should be Empty:

Initial enquiry

Photographs