Hair Transplant Consultation Form | Aesthetics Forms Portal

Hair Transplant Consultation

Client Details

Full Name: *

Date of Birth: *

Contact Number: *

Email: *

Are you currently taking any medications? *

Please list: *

Do you have any allergies? *

Please list: *

Consultation

1. When did you first notice your hair loss? *

2. What first made you aware of your hair loss? *

3. What concerns do you have about hair transplant surgery? Please select all that apply. *

Pain Scarring Cost Doesn’t look natural Other

If Other, please specify:

4. Are you willing to go bald or shave your head? *

5. Where is your hair loss most bothersome? *

6. What bothers you most about your hair loss? *

7. What other hair loss options have you tried? Please select all that apply. *

Propecia Laser hair therapy Supplements Hair products Rogaine PRP Hair System Previous hair transplant surgery None

8. What would be the best thing about having your hair back? Please select all that apply. *

I’d look younger I’d feel more attractive I’d feel more confident I could style my hair the way I want Other

If Other, please specify:

9. If possible, please upload clear photos of your hair loss to help us be better prepared for your appointment:

Any additional questions or comments:

Appointment Guidance

If you have tested positive for COVID-19, or have any symptoms of COVID-19 (see below) please do not attend your appointment. Please contact us as soon as you know you will be unable to attend so we can reschedule.

COVID-19 Symptoms:

a high temperature or shivering (chills) – a high temperature means you feel hot to touch on your chest or back (you do not need to measure your temperature)
a new, continuous cough – this means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours
a loss or change to your sense of smell or taste
shortness of breath
feeling tired or exhausted
an aching body
a headache
a sore throat
a blocked or runny nose
loss of appetite
diarrhoea
feeling sick or being sick