Patient Name*
First and Surname
Address*
Street Address Town/City Postcode
Date of Birth*

DD
MM
YYYY
Mobile Number*
Email Address*
Occupation
This information will help us to assess your individual medical requirements and aftercare advice.
Medical History
Do you have any of the following medical conditions?*
Heart Condition, Diabetes, Liver/Kidney Complaint, Blood Disorder or Allergies?
- Yes
- No
Please include details:
Have you had any other serious illnesses or operations in the past?*
- Yes
- No
Please include details:
Do you have any skin conditions?*
Examples: Keloid, Psoriasis
- Yes
- No
Please include details:
Are you allergic to any medicines or other substances?*
- Yes
- No
Please include details:
Please list any medicines/tablets you are currently taking:
Do you take any blood thinners (e.g. aspirin, clopidogrel, warfarin, apixaban, dabigatran)?*
- Yes
- No
Are you a smoker?*
- Yes
- No
- E-Cigarette
Average cigarettes per day:
Do you drink alcohol?*
- Yes
- No
How many units per week?
Wine: 125ml glass = 1.5 units, 250ml glass = 3 units
Lager/Beer/Cider: Pint = 3 units
Spirits (single small shot) = 1 unit
Your Hair Loss History
When did you first notice you were losing hair?*
Has your hair loss started within weeks or over a longer period of time?
Does anyone in your family suffer from hair loss?*
- Yes
- No
- I don't know
What side of the family?
- Father's side
- Mother's side
Have you tried any hair loss treatments before?*
- Yes
- No
Please list examples:
Examples: Finasteride (Propecia), Dutasteride (Avodart), Minoxidil (Regaine), Derma Rolling, PRP, HRP, Vitamins or Supplements.
Have you had any previous hair loss procedures?
Any special dietary requirements?
Patient Hair Photos

Please upload several photos for your medical file.
Patient Photos*
Drop files here or
Data Collection*
* I consent to my submitted data being collected and stored
The submitted data is used solely for the purpose of your surgeon, other health professionals involved in your care and Hair Repair Clinic to help ensure that you receive the best possible care. Your data is not shared with any other organisation or third party.