Contact Details

Patient Name *

Address *

Town/City *

Postcode *

Phone *

Email *

Date of Birth *

Occupation

Medical History

Do you have any of the following medical conditions?

Heart Condition, Diabetes, Liver/Kidney Complaint, Blood Disorder or Allergies? *

Yes

Please include details of your medical conditions *

Have you had any other serious illnesses or operations in the past? *

Yes

Please include details on your illnesses or operations *

Do you have any skin conditions? (Examples: Keloid, Psoriasis) *

Yes

Please include details on your skin conditions *

Are you allergic to any medicines or other substances? *

Yes

Please include details on your allergies *

Please list any medicines/tablets you are currently taking *

Do you take any blood thinners (e.g. aspirin, clopidogrel, warfarin, apixaban, dabigatran)? *

Yes

Are you a smoker? *

Yes

E-Cigarette

Average cigarettes per day *

Do you drink alcohol? *

Yes

How many units per week? *

Your Hair Loss History

When did you first notice you were losing hair? *

Does anyone in your family suffer from hair loss? *

Yes

I don't know

What side of the family? *

You can select both if that's the case

Father's side
Mother's side
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Have you tried any hair loss treatments before? *

Yes

Please list examples *

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 - .jpeg, .jpg, .png

Consent *

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 Surgery Group Ltd to help ensure that you receive the best possible care. Your data is not shared with any other organisation or third party.