Online Consultation Consult FormName* First Last Mobile*Email* Gender* Male Female Date of Birth* Day Month Year What are your hair regrow goals?* Get my hair back Full head of hair Stop thinning Make it fuller I want to feel good about how I look I want to score a good looking partner I want to be more confident I want to restore my former glory I want hair loss off my mind Other Other* What would be the best thing about having your hair back?* I’d feel younger and more attractive I’d feel myself again I’d feel more confident and less insecure Other Other* When did you first notice your hair loss?* It’s just started It’s been way too long It’s been happening for a while How did you first notice your hair loss?* Chunks of hair in my hand It was in the sink There was more hair stuck on my hair brush I could see my scalp In the mirror after a shower My partner noticed it What bothers you most about losing your hair?* Thinning hair makes me look older I feel less attractive Makes me feel insecure Other Other* How rapidly have you been losing hair?* Very fast Slowly over time Fell out in patches Where are you losing hair from?* Hairline/front of the head Crown/middle of the head Thinning all over Temples In patches Combination Have your eyebrows or eyelashes ever been affected by hair loss?* Yes No Are you or have you been experiencing an abnormally high level of mental or physical stress recently? Such as anxiety or depression.* Yes No Do you suspect any medical reason for your baldness?* Yes No Enter* Do you have any known allergies?* Yes No Enter Allergy Names* Are you taking any types of Steroids? Testosterone Boosters/HGH etc?* Yes No Which One?* Has anyone in your family experienced hair loss.* Yes No Which picture most resembles your current degree of hair loss? Men lose hair in several common patterns.* How motivated are you to do something about your hair loss?* I’m very motivated I’m not ready yet I don’t know Are you willing to persist with your hair loss treatment for 6 - 12 months?* Yes No Have you tried any of these treatments before?* Oral supplements Topical solutions Regenera/PRP Wigs Fibers Minoxidil Finasteride Dutasteride Combination of the above Non-medical treatment No previous treatment Other Other* What option are you most interested in?* Hair Transplant Prescription Treatment Plan
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