Telogen Effluvium

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)

PAGE 3 - PICTURES: Pictures should be preferably taken with your face uncovered. Your privacy is guaranteed and the pictures will only be kept in the clinic database. It's very import that you take the pictures following these rules: DON'T USE FLASH TAKE YOUR PICTURES FROM A DISTANCE OF 80 CM - 1 METER (32 - 40 INCHES) PREFERABLY TAKE YOUR PICTURES WITH A DIGITAL CAMERA NOT WITH A WEBCAM NOR A CELLPHONE WITH LOW RESOLUTION TRY TO FOCUS ON THE BALD, THINNED AREAS AND DON'T COVER THEM TAKE YOUR PHOTOS IN EXTERIORS UNDER NATURAL LIGHT Poses are very important, and the following images are needed: FRONTAL VIEW - Show at least your eyebrows COMPLETE LEFT AND RIGHT SIDE COMPLETE TOP VIEW COMPLETE VIEW OF THE DONOR AREA
FRONT VIEW*
Accepted file types: jpg, jpeg, gif, tiff, png, bmp, Max. file size: 256 MB.
Show at least your eyebrows
LEFT SIDE
Accepted file types: jpg, jpeg, png, bmp, gif, tiff, Max. file size: 256 MB.
RIGHT SIDE PICTURE*
Accepted file types: jpg, jpeg, gif, tiff, png, Max. file size: 256 MB.
TOP VIEW PICTURE*
Accepted file types: jpg, jpeg, gif, tiff, png, bp, Max. file size: 256 MB.
BACK VIEW (DONOR AREA PICTURE)*
Accepted file types: jpg, jpeg, gif, png, tiff, bmp, Max. file size: 256 MB.
EXTRA PICTURE
Accepted file types: jpg, jpeg, tiff, gif, png, bmp, Max. file size: 256 MB.
Do you have another picture that you want to show to the doctor ? Please upload it !
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