1. PATIENT INFORMATION

Forename *

Family Name *

Date of Birth *

Age

Gender *
Select…MaleFemaleOtherPrefer not to say
Address *

City *

Postcode *

Country *

Mobile *

Email *

Occupation

Next of Kin

Relation

Contact

GP Name / Practice

GP Contact

Preferred Method of Contact *

Email

Phone

WhatsApp

Other

2. MEDICAL HISTORY

Please tick or specify as applicable. This information is confidential and helps ensure your safety during treatment.

Are you generally healthy and fit? *

Yes

No
If no, please describe any current or past medical conditions:

List all medications, supplements, or herbal remedies currently used:

Allergies (medications, latex, anaesthetics, etc.):

Any bleeding or clotting disorders?

Yes

No
History of fainting, dizziness, or anaesthetic reactions?

Yes

No
Do you have or have had:

Heart disease / high blood pressure

Diabetes

Thyroid disorder

Asthma / breathing issues

Liver / kidney disease

Hepatitis B/C or HIV

Epilepsy

Depression or anxiety
Do you smoke?

Yes

No
If yes, how many per day:

Alcohol:

Yes

No
Drinks per week:

Have you ever had abnormal scarring or keloid formation?

Yes

No

3. HAIR LOSS HISTORY

When did your hair loss start?

Is there a family history of hair loss?

Yes

No
If yes, who?

Describe areas affected:

Frontal

Crown

Mid-scalp

Beard

Other
Previous treatments (e.g., minoxidil, finasteride, PRP):

Have you had a hair transplant before?

Yes

No
Year / Clinic:

Graft count (if known):

Any complications or unsatisfactory results (scarring, pitting, wrong direction, etc.)?

4. CURRENT HAIR & SCALP ASSESSMENT

Do you have any of the following:

Dandruff

Psoriasis

Eczema

Infection

None
Hair texture:

Straight

Wavy

Curly
Hair colour:

5. LIFESTYLE & HABITS

Do you exercise regularly?

Yes

No
Type / Frequency:

Typical diet:

Omnivore

Vegetarian

Vegan

Other
Sleep quality:

Good

Fair

Poor
Average hours/night:

6. PROCEDURE-RELATED QUESTIONS

Main reason for seeking hair transplantation:

Which areas would you like treated?

Hairline

Crown

Beard

Other
Desired hairline style:

Natural

Youthful

Conservative
Do you understand that results vary and multiple sessions may be required?

Yes

No
Are you aware of post-operative care requirements?

Yes

No

7. CONSENT CONFIRMATION

Please confirm by ticking below that you have received and understood the following documents/information:

Patient Information Leaflet – FUE & BHT

Pre- and Post-Operative Instructions

Consent Form for FUE/BHT Procedure

Discussed risks, benefits, and alternatives with Dr. Hussain
Patient Declaration:

I confirm that the information I have provided is complete and accurate to the best of my knowledge.

I confirm the above declaration *
Full Name (as signature) *

Date *


SUBMIT FORM

By submitting this form, you consent to My Hair Clinic processing your personal data for the purpose of your treatment and care.