CONSULTATION

Name and Surname*

Prefix Name Surname

Address*

Street + number City ZIP / Postal Code Country

Telephone*

Insert your telephone number

Date of birth*

Insert your date of birth

Email*

Insert the e-mail address where you would like to receive the evaluation

Do you use Finasteride ?*

Please specify if you are using Finasteride (Propecia or Proscar)

Do you use Minoxidil ?*

Please specify if you are using Minoxidil

Have you undergone a hair transplant surgery in the past ?*

Which surgical tecnique has been used during your previous surgery ?*

Year of your previous surgery*

How many grafts did you receive in your previous surgery ?*

Please insert a value between 100 and 7500

Which doctor performed your previous surgery ?*

Have you undergone more than one hair transplant surgery in the past ?*

Please give us as many details as possible of your previous surgeries (number of grafts, technique used, doctor who performed the surgery)