Online Enquiry Form

Please fill out the enquiry form and upload your photos. Our Aushair Specialist will determine your level of hair loss and then provide professional advice regarding your specific condition

Name*
Phone
Mobile*
Your Email*
Street Address*
Suburb*
State*
Post Code*
Your Age*
Your Gender

Male Female 

Is this your first time consulting with us?

Yes No 



[Note : Are you allergic to alcohol-based products? - If Yes, Unfortunately, there is no treatment available.]

Do you have any history of illness such as

 Liver disease Kidney failure Diabetes Cushing's Syndrome Addison's Disease Hypoglycemia Anemia Anorexia Nervosa


Have you used any other hair loss treatments in the past?

Yes No 


Are you currently taking any of the following medication?

 Anti-cholesterolemic Anti-coagulants Anti-mitotic agents Anti-ulcerants Beta-blockers Psychotropics Retinoids Allopurinol Danazol Interferon Levodopa Vitamin A, vitamin D or Fosamax


What type of hair loss do you have?

 Diffuse Patchy Baldness

Do you have family history of hair loss?

 Father side Mother side Brother Sister None

How is your sleep?

Good Poor 


 Have you permed or straightened your hair before?
 Have you changed your diet recently?
 Are you vegetarian?


Please rate your stress level

 No Normal Moderate Severe

How did you hear about us?

Online Flyer Friend/family Clinic/retail outlet 

Other outlets


Ears as close to edge as possible, must see the whole thinning area of scalp, directly in front of subject. Take photo 1.0 meter from subject’s head. Separate the hair from the center, making a part in the middle and focus camera shot on most affected area the area.


Front Photo   

Ears as close to edge as possible, must see the whole thinning area of scalp, directly behind subject. Take photo 1.0 meter from subject’s head. Separate the hair from the center, making a part in the middle and focus camera shot on most affected area.


Rear Photo   

Nose and back of head close to edge as possible, directly side on, lift hair up with opposite hand to show the thinning area of temple, look up. Take photo 1.0 meter from subject’s head and focus camera shot on most affected area.


Side Photo   


Note -: Please be sure to record the distance between your head and camera as you will need the exact same distance for your after photo comparison.

Any other comments?

Call 1800 001 101 to Book an Appointment OR Enquire Online

Enquire Online