Form Test

Name *

Last Name

Phone

Sex *

Email Address *

Age *

Height (ft)

Where are you contacting us from?

Address

Country

City

State

Zip / Post Code

What type of hair transplant are you interested in?

Type of Treatment

FUE Transplant
PRP Treatment
Other

Have you had any allergies or medical issues? If so, please explain them below:

Yes
No

Allergies or Medical Issues

When did you first begin noticing the loss of hair?

Have you done any other type of hair loss treatment before?

Yes
No

Can you please tell us what type of treatment did you do?

How long ago was this treatment done?

What type of treatment did you do?

What are you trying to achieve?

Where are you contacting from? *

US
MX

Are you interested in a particular location?

Tijuana Clinic
Leon Clinic
Flexible to location

Method of Contact

Tutorial

Please upload 5 pictures regardless of the problematic areas you want to cover so that our medical team can make an accurate evaluation (see images for guidance on how to take pictures).

File Upload

Picture 1

Picture 2

Picture 3

Submit

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