Consult Form Country of residence*First name and last name*Email Address Phone Number*Gender*FemaleMaleHistory of the disease (diabetes, high blood pressure, etc.)*Age of hair loss*Age*History of surgical problems (colloid formation or excess flesh, bleeding, etc.)*History of hair transplant surgery in the past*YesNoFamily history of hair loss*YesNo40/5000 At what time and by whom?*Medications you have taken so far:List of drugs*Medicine nameFromUntil Hair Type*ThinMediumThickHair Color*Please specify the pattern of your hair loss based on the available photos*Type 1Type 2Type 3Type 4Type 5Type 6Type 7Type 8What do you expect from the outcome of the treatment? (Please specify your expected rate in percent)*Please upload the following photos for a better evaluationThe upper part of the head*The left part of the head*The right part of the head*The back of the head*Hair growth line in front of the head*
