Name and surmane *
Age *
Address *
City *
Province *
Country *
Post code *
Email *
Telephone *
How did you learn about us?
What is the hair loss like in your family (parents, grandparents, uncles)…
Age when first signs of alopecia appeared
Do you consider your alopecia to have stopped advancing?
Medical treatments which you have adopted to stop your hair loss (Finasteride, Minoxidil, others)…
Degree of baldness
What are your expectations of a hair transplant? (restoration of the front hair line, crown):
Have you consulted any professional about your hair loss?
If so whom?
What was your diagnosis?
Have you had any kind of hair transplant?
If so by whom?
Any additional comments you would like to make?
If you wish, you can send your photos
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