Step 1 of 4 25% First and Last Name (required)* Name Surname Address (required)* Street/Square/Street and house number City Phone (required)*Enter your phone numberDate of birth (required)* Enter your date of birth Email (required)* Enter email Email Confirmation Enter the email address to which you would like to receive the evaluationDo you use Finasteride ?*SiNoIndicate whether you are using Finasteride (Propecia or Proscar)How long have you been using Finasteride? Do you use Minoxidil ?*SiNoPlease indicate whether you are using MinoxidilHow long have you been using Minoxidil? Have you previously undergone hair transplantation ?*SINOSpecify whether you have undergone hair transplantation in the pastWhat surgical technique was used in your previous surgery ?*Strip - A lozenge of skin was removed from the back of the neckFue - Follicles were removed one by one with a punchBHT - Follicles were extracted from the body/beard.Year of previous surgery How many follicular units did you receive ?*Please enter a number from 100 to 7500.Enter the number of follicular units received in the previous surgery Doctor who performed your surgery ? Indicate the name of the clinic at which you had surgeryHave you undergone more than one hair transplant in the past ?*SINOIndicate whether you have undergone other transplants in the past Indicate the number of follicular units grafted in your second transplantation*Please enter a number from 50 to 6000.Surgical technique used for your second transplantation*Strip - A strip of skin was taken from the back of the neckFue - Follicles were harvested one by one with a punchBHT - Follicles were taken from the beard or body.Other surgeries - Description Enter year of surgery, number of grafts, and surgical technique of any other transplants performed What are you interested in? Specialist examination (1) Specialist examination via Skype (2) Regenerative therapies (3) FUE hair transplantation (4) In what month would you like to undergo examination/operation?* PAGE 3 PHOTOGRAPHIC IMAGES:. Photographs should be taken preferably barefaced your privacy is guaranteed and the images remain in the clinics archives. It is very important to send photos following the following rules: DO NOT USE FLASH . TAKE IMAGES FROM A DISTANCE OF 80 CM - 1 METER PREFERABLY USE A DIGITAL CAMERA AND NOT A WEBCAM OR A CELL PHONE WITH LOW RESOLUTION CARE TO EVIDENCE DIRECTED CALVE ZONES AND NOT TO COVER THEM. PREFERABLY TAKE PHOTOS OUTDOOR OR IN NATURAL DAY LIGHT. Poses are very important the following images are necessary: FRONT VIEW - Show at least the eyebrows COMPLETE RIGHT AND LEFT PROFILE FULL TOP VIEW FULL VIEW OF THE DONOR FRONT VIEW*Accepted file types: jpg, jpeg, gif, png, bmp, Max. file size: 256 MB.Insert a frontal image RIGHT PROFILE*Accepted file types: jpg, jpeg, gif, png, bmp, Max. file size: 256 MB.Insert a right profile pictureLEFT PROFILE*Accepted file types: jpg, jpeg, gif, png, bmp, Max. file size: 256 MB.Insert a left profile pictureVIEW FROM ABOVE*Accepted file types: jpg, jpeg, gif, png, bmp, Max. file size: 256 MB.Insert full top viewDONOR AREA (NECK AREA)*Accepted file types: jpg, jpeg, gif, png, bmp, Max. file size: 256 MB.Insert an image of the entire neck areaAuthorization to process personal data* I authorize By ticking this box I authorize the processing of my personal data according to the EU Regulation 2016/679
