Full Name *
Email *
Phone *
Country
Age
Gender —Please choose an option—MaleFemaleOther
Have you had any hair transplants? Please provide details (i.e., dates and types).
List relevant health info that might affect a surgical procedure (i.e. keloids, bleeding, diabetes).
How Did You First Hear About Civas Hair Transplant? —Please choose an option—Internet SearchSocial MediaFriend RecommendationTV/RadioMagazine/NewspaperOther
Submit one different photo for each of the four views (Front, Side/Angle, Top, and Rear)
Photos with dry hair only
Include your entire head. You may block out your face, but very close-up photos are not useful. The doctor needs to see the overall pattern of your hair loss
Front View (Max. 5MB)
Side Angle View (Max. 5MB)
Top View (Max. 5MB)
Rear View (Max. 5MB)
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