Virtual consultation

Please fill out the form below to receive free detailed recommendations from our doctors.
*First name:      
Last name:      
Address:      
P.O.B.:      
City:      
Zip code:      
Country:      
*Phone:      
Please specify a suitable time for us to contact you Yes   Time:
No
*E-mail:      
Hair Loss / Alopecia
Age:      
Sex :      
Hair color:      
Hair:      
Hair structure:      
Please select an image matching your wet hair the most.
    1             4           
    2            4A          
    2A           5             
    3              5A        
    3A           6          
  3VERTEX     7          
   Grade I Grade I    Grade II Grade II     Grade III Grade III
At what age you first encountered a hair loss problem?      
Did you experience more severe hair loss in the recent 5 years?       Yes                  No
Do you have chronically thinning hair in the front hair line zone?       Yes                  No
Do you have chronically thinning hair in the back zone of your head?       Yes                  No
Do you experience hair loss at the top of your head?       Yes                  No
Is your scalp visible through the dry hair?       Yes                  No
Is your scalp visible through the wet hair?
      Yes                  No
Is your hair thinner on the top of your head than at the sides or in the back of the head?       Yes                  No
Have you ever noticed that you need your hair at the sides and in the back of your head cut more often than hair on the top of the head?       Yes                  No
In which area of your head do you experience the most severe hair loss?      
Did you consult a hair restoration specialist ever before?       Yes                  No
Have you taken medicines for hair loss (if yes, please specify)?      
Have you undergone a hair restoration surgery?       Yes                  No
Do you consider a hair restoration surgery to be a possible solution for your hair loss problem? Yes                  No
Have you taken previously or are taking currently the following medicines? Rogaine: Yes, previously
  Yes, currently
Propecia: Yes, previously
  Yes, currently
Would you like to have additional information from us? by mail:   Yes         No
by e-mail: Yes         No
Please attach an image file or image files of the area of your head with a hair loss problem

examples
Photo #1
Photo #2
Photo #3
How did you know about us?      
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