Free Hair Transplant AssessmentHair Transplants

Your Situation

Gender*

Current Age*

Where are you experiencing hair loss? (see image above)*

Frontal Hair Line
Midscalp
Crown
Not Applicable

Are you experiencing hair loss or thinning to the sides and back of the scalp (eg the GREY area in the image above?)*

Yes
No

Is your hair loss appearing in the shape of dots or circles? (like the image above)*

YES - I am losing hair in circles or patches like the image above
NO - I am NOT losing hair like the image above.
Unsure

Are you experiencing hair loss or thinning to any other part of your body?*

Yes
No

When did you first notice your hair loss/thinning?*

Before experiencing hair loss and thinning, was your hair naturally?*

Thick + Coarse + Wiry and it has become thin
Moderate Thickness Hair = that has become thin over time
Naturally thin hair that is becoming thinner over time?
Other

More Detail*

What is the natural colour of your hair?*

Would you say your hair is.....*

Straight
Wavy
Curly

Do you colour or bleach your hair?*

Yes - Bleach
Yes - Colour (permanent)
Yes - Colour (semi-permanent)
No

How often do you wash your hair?*

Daily
3-4 times a week
1-2 times a week

Do you experience a dry, itchy or flaky scalp?*

Yes = regularly
Yes = occasionally
Rarely = because you keep on top of it
Not Experiencing Scalp Issues

More Detail - How do you control it normally?*

Do you use shampoo + conditioner?*

Shampoo + Conditioner all the time
Shampoo mainly - sometimes use conditioner
Use a 2-in-1 shampoo and conditioner
Other

More Detail*

Health Review

Approx Weight (in KG please)

Approx Height (in CM please)

When was the last time you had a blood test?

Did the blood test reveal?*

Other*

Do You?*

How Much? How Often, etc.*

In the last 12mths has your weight changed?*

Reason for the change? Stress, poor diet, going to the gym, health issues etc.

How would you describe your diet + nutrition levels normally?*

Very Good
Good - to - Ok
Poor

Do you take any vitamins or supplements?*

When did you last complete a cycle of steriods or human growth hormones or peptides?*

How long did you consume it for?*

Did you notice a change with your hair at all either during or just after your cycle?*

About your hair loss?

What do you think is causes your hair loss?*

What have you tried in the past to treat your hair loss/thinning?*

Ashley and Martin
Advanced Hair
Finasteride (aka Propecia / Proscar or a tablet you cut into 1/4)
Minoxidil (aka Regaine, Rogaine Hair-A-Gain as a lotion or foam)
Laser Comb or Cab
Herbal or Natural Treatments
Other
Not Tried Anything

What do you want to achieve?*

Your Details

Title*

Name*

First Last

State*

Email*

Enter Email Confirm Email

Phone*

Please attach a photo of your hair loss situation.

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Online Hair Transplant Assessment

Summary:

Online Assessment Form

Your Situation

Health Review

About your hair loss?

Your Details