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Hair Loss Treatment

HAIR LOSS TREATMENT PACKAGE INQUIRY FORM

Please fill in the form below and send it to us. One of representative will get back to you within the next 24 hours with a tailor-made package prepared for you.

For more accurate diagnosis you should see our consultant personally. But if you send your photos, please ensure they show current hair loss from different angles. Please attach photos in sizes not exceeding 200 KB.

* Required Fields
Title
First name *
Surname *
Email address *
House number and street *
City/Town *
County *
Postcode
Birthday *   
Sex Male
Female
Type of Hair Thin
Medium
Thick
Waviness Straight
Wavy
Pretty curly
Colour
Do you have a family history of hair loss? Yes
No
Hair Loss Type  
Type 1 Type 2 Type 3 Type 4
Type 5 Type 6 Type 7 Type 8
Which treatment are you considering? * FUE (Follicular Unit Extraction) No strip excision
FUT (Follicular Unite Transplantation) strip tecnique
Both
Your expectations? restore the front hairline
mid scalp
back
your entire balding area
Have you had any previous treatment for hair loss? Yes
No
Any additional info
Please attach photos for further evaluation.
(Up to 200 KB)
Photo1: 
Photo2: 
Photo3: 
Month you want to visit
Flight
Make a Flight search for me and add it to my package
Departure Airport :
I will make my own Flight search
Accommodation
Make a Hotel search for me and add it to my package
Destination City :
I will make my own Hotel search
Airport Transfer
Make a Airport Transfer search for me and add it to my package
Destination City :
I will make my own Airport Transfer search
Please provide further information: By post
By email
By telephone
Please call me to discuss your services: In the daytime
In the evening
Do not call me
Phone no. *
From time to time, we may email you information about healthcare services that may interest you. Your contact details are NOT disclosed to third parties, and will not be sold to spam emailers. We are ANTI SPAM. If you do not wish to receive such email communication from us, please indicate below.
Email Preference I am happy to receive occasional emails
I do not wish to receive occasional emails
Would you also like us to assist you with? * Airport Transfer
Car Rental
Guided City Tours
Full or Parttime qualified tourist guides
Additional activities (golf, skiing, trekking, horseback riding...)
Ant other request

 











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