Name*
First Last
Please select your procedure or treatment*
- Hair Transplant
- Facial Hair Transplant (eg: beard, eyebrow, eyelash)
- Hair Loss Medication
- HRP (home hair recovery program)
- PRP (platelet rich plasma) Therapy
- Other (please enter details in the comments box)
Comments
Please enter details of the treatment you are interested in.
Gender*
- Male
- Female
Date of Birth*

Day
Month
Year
Email Address*
Mobile Number*
Address*
Please include your postcode so we can find the nearest clinic for you.

Postcode
Occupation
To assess and advise on your aftercare it would be great if you would describe the work you do, in other words how physically demanding your job is.
How did you hear about us?
We would love to know how you found Hair Repair Clinic, thanks in advance!
- Web Search (Google, Bing, Yahoo....)
- Social Media (Facebook, Twitter, Reddit....)
- Google Maps
- Email
- Friends and Family *
Comments

* Friends and Family
Did you know we pay a referral fee if your friend/family member books a procedure with Surgery Group? Contact us to find out more.
Assessing you hair loss
Which of the images below is closest to your hair loss pattern?*
Which of the images below is closest to your hair loss pattern?*
Patient Photos

Please include at least two photos as shown
Front View
Max. file size: 512 MB.
Front View
Max. file size: 512 MB.
Side View
Max. file size: 512 MB.
Side View
Max. file size: 512 MB.
Back View
Max. file size: 512 MB.
Back View
Max. file size: 512 MB.
Top of Head View
Max. file size: 512 MB.
Additional Angles
Any additional angles you wish to include
Max. file size: 512 MB.
Data Collection*
- I consent to my submitted data being collected and stored
We treat your information with respect.
The submitted data is used by your surgeon, your patient coordinator at Hair Repair Clinic and other health professionals to help ensure that you receive the best possible care.
Your data is not shared with any other organisation or third party.