SPECIAL OFFER !
 
From April 15  to  May 31, 2018, the clinic will be offering a special rate of 3 € for FUE surgeries. It is on a first come, first serve basis.  Please fill out this form to claim your discount.  
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Online Consultation Form












PERSONAL DETAILS


DATE OF BIRTH*

GENDER

MaleFemaleOther


HAIRLOSS DETAILS


HAIR LOSS CLASS

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HAVE YOU HAD A HAIR TRANSPLANT BEFORE ?*

YesNo

DATE PERFORMED

DO YOU USE MINOXIDIL ?*

YesNo

DO YOU USE PROPECIA ?*

YesNo

PREFERRED METHOD



OTHER INFORMATION