FOLiQA Intake Form

A few questions so we can prepare your written assessment. This should take 2–3 minutes.

We are independent — we don’t work for clinics.

Your answers are confidential. One front photo is required — it's essential for a meaningful assessment. Additional photos are optional but helpful.

Basic information

Full name

Email address

We'll only use this to follow up on your request

WhatsApp number (optional)

For faster communication before your screening (optional)

Country

Gender

Male

Female

Non-binary

Prefer not to say

Age

Enter your age in years

Your situation

What are you mainly concerned about?

Hairline recession at the temples

Thinning across the top or crown (sides look normal)

Thinning along the parting line

Diffuse thinning (entire scalp including sides and back)

Hairline lowering (cosmetic, no active loss)

I'm not sure

This helps us identify the pattern more precisely — some types of hair loss aren't suitable for transplantation

How would you describe the extent of your hair loss?

I haven't noticed any hair loss

Mild — I've noticed some changes but my hair still looks mostly normal to me

Moderate — the change is noticeable and is probably visible to others

Advanced — significant areas of thinning or loss visible from multiple angles

Severe — very extensive loss; hair remains mainly at the sides and back

Has anyone in your family experienced significant hair thinning or loss?

Mother

Maternal grandmother

Maternal grandfather

Father

Paternal grandmother

Paternal grandfather

Siblings

None that I'm aware of

When are you considering a transplant?

As soon as possible

Within 3 months

In 3–12 months

Just researching

Have you already spoken to any clinics?

Yes

Have you used any medical hair loss treatments?

Finasteride (oral)

Dutasteride (oral)

Minoxidil (topical)

Minoxidil (oral)

Low-level laser therapy (LLLT)

None

What is your approximate budget

Rough estimate — even if you're just researching, this helps us give you realistic context.

What is your approximate budget

Less than €2,000

€2,000–€4,000

€4,000–€6,000

More than €6,000

Not sure yet / open to guidance

Photos

To give you meaningful guidance, we strongly recommend at least one clear photo.

If you're comfortable, upload photos in good lighting. These are confidential and only used for your assessment.

Front photo

Tip: Natural light, no flash, hair dry and unstyled. Wear it as you normally would — not pushed forward to cover the hairline or swept back to expose it. Doesn't need to be perfect.

Accepts image files

Size limit: 10 MB

Top photo (optional)

Accepts image files

Size limit: 10 MB

Crown photo (optional)

Accepts image files

Size limit: 10 MB

Donor / back photo (optional)

Accepts image files

Size limit: 10 MB

Temples / sides (optional)

Left and right sides showing the hairline shape at the temples. Please upload one photo for each side. Helpful if recession is your main concern.

Accepts image files

Size limit: 10 MB

Anything else

Anything else we should know?

Data consent

I consent to FOLiQA (FOLiQA Health ehf.) collecting and processing my personal data and health information for the purpose of preparing my advisory assessment. I understand that my data may be shared with clinics I am referred to, that referral fees may apply (always disclosed), and that my anonymized data may contribute to FOLiQA's outcomes database if I separately agree to this. I have read and accept the Privacy Policy - https://foliqahealth.com/privacy-policy.

Outcomes Data Consent (Optional)

I consent to my anonymized outcomes data (satisfaction scores, graft count variance, surgeon involvement) being used in FOLiQA's clinic evaluation database to help future patients. This is optional and does not affect my assessment.