Personal Information

*First Name:

*Last Name:

*Preferred Contact Number:

Address:

*Email:

City:

Hair Color:

State:

*Age:

Country:

Gender:

2. What donor source do you anticipate using? Head hair SFET only, Body hair SFET only OR a combination?

Head Hair SFET onlyBody Hair SFET onlyCombination

3. Have you had Hair surgery before? If yes, give details including the doctor, date, satisfaction level etc.

YesNo

4. Have you consulted with other hair transplant or cosmetic surgeons for the same problem(s) that brings you here today? If yes, give details including doctor, date, outcome of consultation etc.

YesNo

5. Are you currently being treated for any medical, surgical or psychological condition? If yes, please give details including medications you are currently taking etc.

YesNo

6. Have you been treated for any medical, surgical or psychological condition in the past? If yes, please give details including medications you have taken in the past etc.

YesNo

7. Are you taking Propecia/finasteride or Avodart/dutasteride? If yes, for how long?

YesNo

8. What are your expectations from the procedure?

9. What are your short and long term goal for hair restoration?

10. Approximate date you would prefer to have your procedure?

11. Preferred method of contact?

PhoneEmail

12. Typical Male Pattern Hair loss:

Class 1 Class 2 Class 2A Class 3 Class 3A Class 3V Class 4 Class 4A Class 5 Class 5A Class 5V Class 6 Class 7

13. Typical Female Pattern Hair loss:

Ludwig (1,2,3,4) Ludwig II (1,2) Ludwig III Advanced Frontal

14. If your hair loss pattern does not conform to any of the above or it is caused by other disease conditions, please provide details and be sure to attach you photographs:

15. Additional questions:

How did you find Dr. Umar and DermHair Clinic? *

Please Choose Google Yahoo YouTube Press Release hairsite.com hairlosshelp.com hairtransplantnetwork.com hairlosstalk.com Other

If you chose Other, please specify below:

Directions for photos:

• Send head shots that show the balding areas. Please pull back any hair that obscures the true state of your hair line. If possible also send some photos with the entire top of the head wetted.
• Include photos of the side and back of your head.
• If you are having body hair transplanted, please include photos of the hair bearing areas of your body from which you want the hair taken. If you are unsure, send photos of all hair bearing areas.
• Include photos of special recipient areas such as scars, eyebrows, eyelashes, moustaches etc.