info@hairrepairclinic.co.uk
FREEPHONE : 0800 832 1899
WHATSAPP : 07855 565558
×
Men
Hair Transplants
Platelet Rich Plasma
Hermetic Hair Recovery
Hair Loss Medication
Scalp Micro Pigmentation
Eyebrow Transplants
Beard Transplant
Women
Hair Transplants
Hermetic Hair Recovery
SMP
Eyebrow Transplants
Eyelash Transplants
Results
Blog
Patient Stories
Patient Stories Ben
Patient Stories Michael
Patient Stories Chad
Contact us
MENU
Consultation Form
Consultation Form
Name
*
First
Last
Please select your preferred consultation type
Face to Face at the Clinic
FaceTime
Skype
Please select your procedure or treatment
*
Hair Transplant
Facial Hair Transplant
Eyelash Transplant
Eyebrow Transplant
Hair Loss Medication
Comments
Please enter details of the surgery you are interested in
Gender
*
Male
Female
Date of Birth
*
DD
MM
YYYY
Email Address
*
Mobile Number
*
Postcode
*
Occupation
To assess your aftercare accurately please describe the work you do
Which of the images below is closest to your hair loss pattern?
*
Which of the images below is closest to your hair loss pattern?
Frontal
Patches
PATIENT PHOTOS
Front View
Side View
Back View
Top of Head
Front View
Side View
Back View
Additional Angles
Any additional photos you wish to include
Please include photos of the area you are interested in treating
Data Collection
*
The submitted data is used solely for the purpose of Hair Repair Clinic, your surgeon and other health professionals involved in your care to help ensure that you receive the best possible care.
I consent to my submitted data being collected and stored
© 2019 Hair Repair Clinic is a subsidiary of Surgery Group Ltd, registered with Companies House UK under registration number 09630474 and registration address 102 Old Hall Street, Middleton M24 1AG
