Menu

Treatments
Why MHC?
Graft Calculator
Contact us

Book Consultation

Patient Intake Form – My Hair Clinic (UK)

PATIENT INTAKE FORM

FUE & Body Hair Transplantation

My Hair Clinic (UK) – Nottingham

Email: info@myhairclinic.com | Website: www.myhairclinic.com

1. PATIENT INFORMATION

Forename *

Family Name *

Date of Birth *

Age

Gender *

Address *

City *

Postcode *

Country *

Mobile *

Email *

Occupation

Next of Kin

Relation

Contact

GP Name / Practice

GP Contact

Preferred Method of Contact *

Email

Phone

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 *

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

Over 6,000 successful procedures and counting, with clients from across the globe

Book your Consultation now

Trusted by Thousands

What sets Dr Hussain apart is his personalized approach—he carefully assesses each patient’s hair loss pattern, scalp condition, and aesthetic goals to deliver results that are not only effective but seamlessly natural.

Patients choose Dr Hussain for his reputation, attention to detail, and the trust he builds through honest consultation and outstanding care throughout the treatment journey.

Verified Reviews

ABOUT

Menu

Blog
Contact us
Privacy Policy

TREATMENT

Menu

FUE Hair Transplantation
Alopecia Areata
Beard Transplant
Body Hair Transplant

FAQ

Menu

Our Guarantee
Safety & Expertise
What to expect after FUE Hair Transplantation?
Why us?

Facebook Twitter Youtube

English