Please complete: Confidential Questionnaire Name & Surname * Gender * Male Female Date of Birth Email * Phone * Phone * Physical Address * How Long have you been losing your hair? * Please specify working conditions; special interests or hobbies that might affect hair restoration. * Occupation (this may have an external impact). * What have you previously tried to counter hairloss? * Nothing Hairpiece Tablets (specify) Clinical Treatment Laser comb Lotions (specify) Surgical Procedures Shampoos (specify) Specify tablets used to counter hairloss * Specify lotions used to counter hairloss * Specify shampoos used to counter hairloss * Have you completed a hair restoration program previously? * Yes No Who did you see? * Please list any health concerns/conditions or medications that may affect your hair loss: * How did you hear about us? * I Agree I hereby warrant that I am physically and medically fit to proceed with the routine of treatments recommended by Life Hair Restoration Clinic, which I hereby voluntarily undertake. I have read and understand this form and have answered it accurately. By signing this form, I hereby indemnify and hold harmless Life Hair Restoration Clinic, its management, staff, employees and assistants against any claim which may arise from any injury, loss or damage to either my person or property from whatsoever cause arising. If you are human, leave this field blank. Submit
