Online Consultation Form male

Please fill out the consultation form and upload your photos.Our Certified Trichologist will then use this information to help her determine the cause and stage of your hair or scalp condition during your online consultation

    Name*

    Mobile*

    Your Email*

    Street Address*

    Suburb*

    State*

    Post Code*

    Date of Birth*

    Is this your first time consulting with us?

    YesNo

    Do you have any history of illness such as

    Liver diseasKidney failureDiabetesCushing's SyndromeAddison's DiseaseHypoglycemiaAnemiaAnorexia NervosaNone

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

    YesNo

    What products have you used?" "How long did you use them for"?

    Are you currently taking any of the following medication?

    Anti-cholesterolemicAnti-coagulantsAnti-mitotic agentsAnti-ulcerantsBeta-blockersPsychotropicsRetinoidsAllopurinolDanazolInterferonLevodopaVitamin A, vitamin D or FosamaxNone

    Have you consulted another health professional before regarding your hair or scalp condition? If so, did they say you have one of the following conditions:

    Diffuse Hair LossMale Pattern Hair LossFemale Pattern Hair LossAlopecia AreataOther

    Do you have family history of hair loss?

    Father sideMother sideBrotherSisterNone

    How many hours do you sleep usually?

    What is your main concern

    Experiencing a large amount of hair fallHair gradually getting thinnerPatchyGrey hairItchy ScalpDandruff & Flaky

    Duration of Hair loss?

    How often do you shampoo your hair?

    Do you suffer from any other allergies? if so please

    Do you /have you ever had an allergic reaction to alcohol

    YesNO

    Have you changed your diet recently?

    YesNO

    Are you vegetarian?

    YesNO

    How did you hear about us?

    Friend referralFacebookGoolge/websiteWalk byOther

    Have you permed or straightened your hair before?

    yesNO

    Name of friend, if friend referral:

    How often:

    Must see the whole thinning area of scalp. Separate the hair from the center with a comb, making a part in the middle and focus the camera shot on most affected area of the scalp.

    Front Photo 

    Maximum file size for attachment is 5MB

    Lift hair up near the temple with opposite hand to show the thinning area of the temple then look up. Focus the camera shot on most affected area.

    Right Photo   

    Maximum file size for attachment is 5MB

    Lift hair up near the temple with opposite hand to show the thinning area of the temple then look up. Focus the camera shot on most affected area.

    Left Photo   

    Maximum file size for attachment is 5MB

    Must see the whole thinning area of scalp, directly behind subject. Separate the hair from the center, making a part in the middle and focus the camera shot on most affected area.

    Rear Photo   

    Maximum file size for attachment is 5MB

    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?