forma

First Name *

Last Name *

Phone *

Email *

Sex *

Age *

Height (ft)

Where are you contacting us from?

Address

Country

City

State

Zip / Post Code

Type of Treatment

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

Yes
No

Allergies or Medical Issues

Have you had or currently have Hepatitis C? *

Yes
No

Have you had or currently have HIV? *

Yes
No

When did you first begin noticing the loss of hair?

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

Yes
No

How long ago was this treatment done?

What type of treatment did you do?

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).

Please make sure we have a clear view of the area you would like restored.

*If you shave your head, you need 2 weeks hair growth so we can see active follicles.

*If you have longer hair and want to restore your front hairline, please hold it back so we can see your current hairline.

*For longer hair on the top of the head, please finger comb a little water through, so we can see how much density is needed for restoration.

Please also forward a picture of your goal look. This can be a picture of your younger self, or a photo that shows the hairline you hope to restore.

Pictures

Submit

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