My Hair Clinic - Assessment Form

MY HAIR CLINIC

Advanced FUE Hair Transplantation - Assessment Form

Patient Information

Full Name *

Phone Number

Age

Preferred Location

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

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

Front Hairline / Temples

Mid-Scalp / Top

Crown (Read our recommendation below)

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. *