Page 1 of 2

Registration form

Let's start with your personal details

*

What age did you first notice you were losing hair?

*

What area did you first notice you were losing hair?

*

What area did you first notice you were losing hair?

A

Front

B

Back

C

Temples

D

Crown

*

Have you been to see your Doctor or Trichologist regarding your hair loss?

*

Have you been to see your Doctor or Trichologist regarding your hair loss?

A

Yes

B

No

Have you sought your Doctor's permission to have the system fitted?

*

Have you sought your Doctor's permission to have the system fitted?

A

Yes

B

No

Salutation:

*

Salutation:

A

Ms

B

Miss

C

Mrs

Have you had any previous hair loss treatments?

*

Have you had any previous hair loss treatments?

Medication

Laser

Other

Nothing

Is there any family history of hair loss?

*

Is there any family history of hair loss?

Yes

No

If yes, which side?

*

If yes, which side?

mothers side

fathers side

What is your hair type?

*

What is your hair type?

Caucasian/ European

Afro=Caribbean

Asian

Are you looking to non-surgically restore your lost with a hair replacement system?

*

Are you looking to non-surgically restore your lost with a hair replacement system?

Yes

No

Do you take any prescription medication if yes which ones?

*

Do you take any prescription medication if yes which ones?

Yes

No

Please write down prescription here:

*