Contact Us

Contact Us





Personal Information

Name

Lastname

Age

Sex

Profession

Country

City

Postcode

Day phone

Evening phone

Email

At what age did you begin to experience hair loss?

Baldness Pattern for Men

Class 1

Class 2

Class 3

Class 4

Class 5

Class 6

Class7

Treatment Requirement
Do you have a preferred method for your hair restoration?
When are you interested in having your Hair Transplant?

Have you ever had surgical hair restoration performed?
How do you prefer to be contacted?

General Comments:

If you would like to send your photos, please e-mail us