Online Consultation Form

Name Surname *

Email *

Phone *

Country

Age

Gender

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?

Instructions for Photos:

1. Submit one different photo for each of the four views (Front, Side/Angle, Top, and Rear)

2. Photos with dry hair only

3. 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. 3MB.}

Side Angle View {Max. 3MB.}

Top View {Max. 3MB.}

Rear View {Max. 3MB.}

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