1Contact Details

2Medical History

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First Name*

Last Name*

Email*

Phone*

Medical History

This information will help us identify the best treatment solution tailored for your case. Your information will be kept private and secure with us. If you decide not to continue, your details will be deleted after the free assessment.

Age*

Gender*

What are your hair restoration goals and what would you like to achieve?

For example: restore the front hairline, mid scalp, back, or your entire balding area with CIT, Strip or BHT)?

Have you consulted with a doctor about your hair loss condition?*

What is the doctor's name who made your consultation?

What treatment, if any, was recommended?

Are you using any medication to treat your hair loss? (Propecia, Monixidil, Avodart)

Have you ever had surgical hair restoration performed?*

Who performed your surgery?

Do you have any medical issues?*

Any additional questions or comments?

Photo Upload (Optional)

The photo upload is not required but we highly encourage you to do so that our doctors can accurately estimate the graft count and provide you with a proper cost estimate. Accepted file types: jpg, gif, png, pdf, webp, Max. file size: 5 MB

** You can skip to submit if you don't have photos.

Top View

Drop files here or

Accepted file types: jpeg, jpg, png, gif, bmp, tiff, svg, webp, ico, raw, heic, pdf, eps, psd, ai, Max. file size: 10 MB, Max. files: 1.

Front View

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Accepted file types: jpeg, jpg, png, gif, bmp, tiff, svg, webp, ico, raw, heic, pdf, eps, psd, ai, Max. file size: 10 MB, Max. files: 1.

Left View

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Accepted file types: jpeg, jpg, png, gif, bmp, tiff, svg, webp, ico, raw, heic, pdf, eps, psd, ai, Max. file size: 10 MB, Max. files: 1.

Right View

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Max. file size: 10 MB, Max. files: 1.

Crown View

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Max. file size: 10 MB, Max. files: 1.

Back View (Donor)

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Max. file size: 10 MB, Max. files: 1.

Phone

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Medical History

Photo Upload (Optional)

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