Hairclinic

Name and Surname*
Prefix Name Surname
Address*
Street + number City ZIP / Postal Code Country
Telephone*
Insert your telephone number
Date of birth*
DD slash MM slash YYYY

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)