Online Consult

How Would You Like To Be Contacted?*
EmailPhone

Hair Loss Info

What are your hair restoration goals?

Have you had any hair transplants? Please provide details (i.e., dates and types).

List relevant health info that might affect a surgical procedure (i.e. keloids, bleeding, diabetes).

Are you currently taking finasteride (Propecia)?*
YesNo

Are you currently taking minoxidil (Rogaine)?*
YesNo

Other medications?

Photo Uploads

Instructions for Photos:

1. Submit one different photo for each of the four views (Front, Side/Angle, Top, and Rear)

2. Photos with dry hair only

3. Include your entire head. You may block out your face, but very close-up photos are not useful. The doctor needs to see the overall pattern of your hair loss

Front View

Select a photo of your frontal hairline

Side Angle View

Select a photo of your hair from the side

Top View

Select a photo of the top of your scalp

Rear View

Select a photo of the back of your scalp

Reasons for Inquiry

You may select more than one option:
Follicular Unit Transplant (FUT)Follicular Unit Extraction (FUE)Transplant-Beard TransplantEyebrow TransplantRepair Old Hair TransplantHair Stem Cell Treatment

Personal Information

First Name*

Last Name*

Email*

Phone Number

City

Country

Date of Birth

Age

Gender

Current Patient of Civas Hair Transplant?*

General

How Did You First Hear About Civas Hair Transplant?*

Other Referral?

Comments

Online Physician Consultation Form