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Discover Your Hair Regrowth Plan

Please fill out the consultation form and upload your photos. Our 101 Specialist will determine your level of hair loss and then provide professional advice regarding your specific condition

Name : *
Phone : *
Mobile :
Email Address : *
Street Address : *
Suburb : *
State : *
Post code : *
Your Gender : Male Female
Your Age : *
Is this your first time consulting with us? Yes No
Are you allergic to alcohol-based products? - If Yes, Unfortunately there is no treatment available.
Do you have any history of illness such as Liver diseas Kidney failure Diabetes Cushing's Syndrome Addison's Disease Hypoglycemia Anemia Anorexia Nervosa
Have you used any other hair loss treatments in the past? Yes No
Are you currently taking any of the following medication? Anti-cholesterolemic Anti-coagulants Anti-mitotic agents Anti-ulcerants Beta-blockers Psychotropics Retinoids Allopurinol Danazol Interferon Levodopa Vitamin A, vitamin D or Fosamax
What type of hair loss do you have? Diffuse Patchy Baldness
Do you have family history of hair loss? Father side Mother side Brother Sister None
How is your sleep? Good Poor
Have you permed or straight your hair before?
Have you changed your diet recently?
Are you vegetarian?
Please rate your stress level No Normal Moderate Severe
How did you hear about us? Online Flyer Friend/Family Clinic/retail outlet
Please upload your photos - (Front Photo, Side Photo & Back Photo) *
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1. Front View:

Ears as close to edge as possible, must see the whole thinning area of scalp, directly in front of subject. Take photo 1.0 meter from subject’s head. Separate the hair from the center, making a part in the middle and focus camera shot on most affected area the area.

Front Photo:
 
2. Rear View:

Ears as close to edge as possible, must see the whole thinning area of scalp, directly behind subject. Take photo 1.0 meter from subject’s head. Separate the hair from the center, making a part in the middle and focus camera shot on most affected area.

Rear Photo:
 
3. Side View:

Nose and back of head close to edge as possible, directly side on, lift hair up with opposite hand to show the thinning area of temple, look up. Take photo 1.0 meter from subject’s head and focus camera shot on most affected area.

Side Photo:

Please be sure to record the distance between your head and camera as you will need the exact same distance for your after photo comparison.

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