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Please ensure you enter your correct email address and/or phone number or we will be unable to contact you and respond to your questions.

Be aware that if you have a hotmail or gmail email address, your user account settings may cause our replies to end up within your junk mail box. Please check this folder should you not receive a phone call or email within 3 business days.

Ensure you submit your phone number and do contact us back if you have not received a response in 3 business days.

If you are NOT contacting us in relation to hair loss, please fill in the Online Enquiry Form.

Online Consultation Form

An online consultation is an essential first step in us formulating a possible treatment plan for you.

Please complete the consultation form below and attach photos. Please read and follow the photo guidelines before submitting the form. A formal consultation is only possible if the required photos and assessment are submitted. Please ensure that ALL questions are answered.

Photo Upload Restrictions

Photos must not exceed 4MB each. Please resize photos that exceed this limit.

Acceptable photo file types are jpg or jpeg.







MaleFemale

Google SearchFacebookYouTubePhysicianFamilyFriend/Patient

Hair Transplantation SurgeryEyebrow Transplantation SurgeryPRP for Hair LossMedication for hair lossOther (Please enter Comments Below):

Hair Loss History

Within last year1-2 years ago3-4 years5-7 years8-10 yearsMore than 10 years ago

No ChangeSlowModerateFast

IIIIIIIIIaIIIvertexIVIVaVVaVIVII

Image_031

Image_032

YesNo

  Yes No
Frontal/Frontal Hairline Area YesNo
Top (mid scalp) YesNo
Crown (back) YesNo
Temples YesNo
Eyebrows YesNo
Scars YesNo
Other

PAST SURGICAL HISTORY:

YesNo

HAIR LOSS MEDICATIONS:

Finasteride (Eg Propecia) Yes – CurrentlyYes – In the PastNever
Dutasteride (Avodart) Yes – CurrentlyYes – In the PastNever
Minoxidil (Eg Rogaine) Yes – CurrentlyYes – In the PastNever
Spironolactone Yes – CurrentlyYes – In the PastNever
Cyproterone acetate Yes – CurrentlyYes – In the PastNever

Photo Guidelines

So that we can provide the most accurate assessment possible, please use the following hair transplant photo guidelines:

  • Submit digital photos
  • Use bright, natural room lighting. Do not use a flash
  • Shoot from a distance of 2 – 3 feet.
  • Ensure that the area you are shooting is in frame and in focus
  • Photos must not exceed 4MB each. Please resize photos that exceed this limit
  • Acceptable photo file types are jpg or jpeg


Required Photos
For your online hair transplant consultation, please provide photos showing the following angles:

The top of your scalp:

This gives us an overall view of your hair loss situation. The top view is important as it helps us determine the amount of existing hair loss and possible future hair loss.

Left and right profile:
The profile is very important in assessing the needs of our patients. The profile helps us understand the extent of hair loss.

The back of the scalp:
Also if possible, include an extra photograph with your donor hair pulled with a comb (picture 2). This helps us determine your donor density.

Frontal hairline:
We need to be able to understand how your existing or new hairline frames your face. This is imperative for the review process. If possible, take some time to draw your hairline on your scalp to show us where you would like to have it placed (if this is an area that concerns you. This helps us to understand your desires and expectations from the procedure.