Online Consultation

Consultation Form

Use our free tool for a first evaluation of your own hair loss problem by our medical staff.

With our hair loss assessment tool, you can provide us with important information regarding your hair loss problem. Please fill out the questionnaire and submit it and we will contact you with an initial diagnosis made by one of our medical specialists. This evaluation is free of charge and does not require you to book a session of hair transplant at HAIRMEDICO.

Which of the following categories do you belong to? *

As an illustration, please upload a photo of your hair (max 5 Mo / per photo.): A photo showing your face from above

A photo showing your profil
A photo showing the back of your head
How old are you? *
What is your origin? *
What is the color of your hair? *
What is your hair type? *
Do you have a family history of hair loss? *
Have you ever sought another doctor for information? *
If so, which of these methods did he offer you?
Have you ever had another hair transplant? *
If so, which of these methods did he offer you?
Name of your doctor:
Do you smoke? *
Have you been subject to or have you been treated for any of the following:
Other element not listed above?
Are you pregnant? *
Do you take the contraceptive pill? *
Have you ever used any of the medications or products listed below?
Other medication not,listed above?
Do you have healing problems (please set them where appropriate)?
How would you describe your overall health - including your diet and fitness?
Do you have problems with your eyes, eg dry eyes:
Have you ever experienced an allergic reaction to the treatment of general or local anesthesia (Lidocaine or Xylocaine)? *
First Name *
Last Name *
E-mail *
Adress
Postal Code
City
Country *
Profession
Telephone *
Your message
What budget do you have for your hair transplantation? *
How did you hear about us?
I would like to receive further information on advanced HAIRMEDICO hair transplant by e-mail and newsletter.
I agree to the terms and conditions and privacy policy *
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