Scientific Center for Hair Transplantation

Online consultation

Online consultation
Hair loss/Baldness
Private information will be transferred using the secured server. All the data you have entered will be used by our specialists to recommend you further. The information that we will get from you will be kept as confidential. * (marked by) means that it’s compulsory to fill in the form
First Name: *
Surname:
Address:
City:
Country (Your current occupation):
Telephone number: *
Can we connect to you through the telephone? If yes, When is it best to call you?:	Yes preferred timing: No
E-mail: *
Age:
Sex:
Hair Color:
Your hair is:
Hair structure:
Mark the picture that describes your hair best when it’s wet.


When did your hair loss begin?:
Did the hair loss increase n the last 5 years?	Yes No
Have you observed any hair loss on frontal length of the hair?	Yes No
Have you ever observed the constant hair loss on the back of the head?	Yes No
Have you noticed the hair loss from the crown?	Yes No
Is the scalp visible from the dry head of hair?	Yes No
Is the scalp visible from the wet head of hair?	Yes No
Is the hair on the crown thinner then on each side and back of the head?	Yes No
Have you noticed that your hair should be cut on each side and back more often than on the crown?	Yes No
On which part of the head the alopecia is the largest problem for you.
Have you ever consulted the specialist with the alopecia problems?	Yes No
If you have taken any medicines against the hair loss, please state!
Have you ever had hair transplantation?	Yes No
Do you think that the hair transplantation will solve your problems with alopecia?	Yes No
Have you ever taken	Rogaine: in the past Now Propecia: in the past Now
If you need any additional information please e-mail.	Yes No
Upload the photos of the part of the head where you experience an increased hair loss	Photo #1 Photo #2 Photo #3
How did you know about us?
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