The world leader in hair transplantation

PERSONAL INFORMATION

Last name *

First Name *

Id Number

Date of birth *

Gender

Address *

Zipcode *

City *

Country

Mobile Phone 1 *

Mobile Phone 2

E mail *

History of hair loss

Hair loss since (year)

Stable/progressive

Localisation

Hair color

Hair structure

Scars/other problems with scalp skin

Medication against hair loss

Other transplants

Hair transplantations in the past

Other remarks

Medical history

Current disease(s)

Coagulation disease(s)

Treatments in progress

Anticoagulation: (blood thinning medication)

Do you use any vitamins?

Do you have any allergies?

Do you smoke?

Alcohol use

Occupation

Do you exercise?

Can we shave your hair 2mm short for the treatment?

What are your expectations of the result?

Please send us 3 photos (the top, the side and the back of the skull) by uploading them below *

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(copy) *

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Caselle di Spunta *

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