VIRTUAL CONSULTATION Through this form you can obtain a surgical evaluation and a quote from the clinics mentioned below. Always check for spam if you do not receive a reply within 7 working days. Fields marked with "*" must be filled in. Step 1 of 4 25% Name and Surname (mandatory)* First Last Address (mandatory)* Street Address City AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Telephone (mandatory)*Enter your phone numberDate of birth* Enter your date of birth Email (required)* Enter Email Confirm Email Enter the email address where you would like to receive the evaluationDo you use Finasteride?*YesNoIndicate whether you are using Finasteride (Propecia or Proscar)Da quanto tempo utilizzi Finasteride? Do you use Minoxidil?*YesNoIndicate if you are using MinoxidilDa quanto tempo utilizzi Minoxidil? Have you had a hair transplant before?*YesNoSpecify whether you have undergone a hair transplant in the past What surgical technique was used in your previous surgery? *StripFUEBHTAnno del precedente intervento How many follicular units did you get?*Please enter a number from 100 to 7500.Enter the number of follicular units received in the previous surgery Doctor who operated on you? Indicate the name of the clinic where you have performed the surgeryHave you had more than one hair transplant in the past?*YesNoIndicate whether you have undergone other transplants in the past Indicates the number of grafted follicular units in your second transplant*Please enter a number from 50 to 6000.Surgical technique used for your second transplant*Strip - A strip of skin was taken from the back of the neckFue - The follicles were taken one by one with a punchBHT - The follicles were taken from the beard or bodyOther HT - Description Enter year of surgery, number of grafts and surgical technique of any other transplants performed A cosa sei interessato? Visita specialistica (1) Visita specialistica via Skype (2) Terapie rigenerative (3) FUE hair transplantFUE hair transplant In what month would you like to operate?* Which areas would you like to deal with? * Zone 1 - Temples Zone 2 - Hairline Zone 3 - Mid high scalp Zone 4 - Mid low scalp Zone 5 - Vertex Zone 6-7 - Crown Indicate the areas you wish to treat PAGINE 3 PHOTOGRAPHIC IMAGES: Photographs should preferably be taken with your face uncovered your privacy is guaranteed and the images remain in the clinic archives. It is very important to send photos according to the following rules: DON'T USE FLASH FRONTAL VIEW*Accepted file types: jpg, jpeg, gif, png, bmp, Max. file size: 256 MB.Insert a front image RIGHT PROFILE*Accepted file types: jpg, jpeg, gif, png, bmp, Max. file size: 256 MB.Insert a right profile imageLEFT PROFILE*Accepted file types: jpg, jpeg, gif, png, bmp, Max. file size: 256 MB.Insert a left profile pictureOVERHEAD VIEW*Accepted file types: jpg, jpeg, gif, png, bmp, Max. file size: 256 MB.Insert a complete top viewDONOR AREA (NECK AREA)*Accepted file types: jpg, jpeg, gif, png, bmp, Max. file size: 256 MB.Insert an image of the whole neck areaAuthorization for the processing of personal data* I authorize By ticking this box I authorize the processing of my personal data according to EU Regulation 2016/679
