MY HAIR CLINIC

Advanced FUE Hair Transplantation – Assessment Form

Patient Information

Full Name *

Email

Phone Number

Age

Preferred Location

Hair Loss Assessment

Select your current hair loss stage (optional but recommended for accurate assessment):

NW2
Minimal Loss

NW3
Early Loss

NW4
Moderate Loss

NW5
Significant Loss

NW6
Advanced Loss

NW7
Severe Loss

Areas to Restore

Select the areas you wish to restore (at least one required):

Front Hairline / Temples

Mid-Scalp / Top

Crown (Read our recommendation below)
Crown Restoration Notice:
We generally do not recommend prioritizing crown transplantation. Our main focus is the front and top for a visible, natural frame to the face.

Hair Characteristics (Optional)

These factors help refine your assessment:

Hair Thickness

Donor Area Density

Hair Texture

Medical History

Have you had any previous hair transplant surgery?

Yes

No
Note: Repair cases may require modified planning and additional consultation.
Still losing hair / Haven’t lost everything yet

Enable this if you’re experiencing ongoing hair loss or in early stages

I understand this is an assessment and consent to My Hair Clinic contacting me about my hair restoration consultation. *

Thank You!

Your hair restoration assessment has been successfully submitted. Dr. Mazhar Hussain’s team will calculate your personalized graft estimate and contact you within 24 hours with detailed results and treatment recommendations.

What happens next: