My Hair Clinic - Assessment Form

MY HAIR CLINIC

Advanced FUE Hair Transplantation - Assessment Form

Patient Information

Full Name *

Email *

Phone Number *

Age *

Preferred Location

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

Note: You can select one front area option + crown if needed

Front Hairline

Front Hairline + Temples

Front Hairline + Temples + Mid-Scalp

Crown

These factors help refine your assessment:

Hair Thickness

Donor Area Density

Hair Texture

Have you had any previous hair transplant surgery?

Yes

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. *