Home - Online Consultation Form
Name Surname *
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Age
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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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