Name: *

Surname: *

Address: *

Zip: *

City and country: *

Email *

Telephone number or cell phone number *

Have you had Hair Transplant Surgery before?
 One Many None

If yes, which Hair Restoration technique was used?
 FUT “strip” surgery FUE surgery BHT (bodyhair)

Total number of grafts used:

Year of surgery done:

Do you use one or more hairloss medications or lotions:
 Propecia / Proscar Minoxidil Dutasteride Saw Palmetto

Other:

Wich area(s) would you like have treated?:
 1 2 3 4 5 5v

Pictures
Pictures should be as sharp as possible and taken without a flash light. The best distance to shoot a photo would be around 31.5 -39 inches (80-100 cm) in a clear space. Please make pictures from different angles for example of your donor area, sideview or balding areas that need to be treaten.
Attention please! Too large pictures (large file size) should be send directly from your email to our mailbox at info@ebersonhairclinic.nl

Picture 1 front:
Picture 2 top:
Picture 3 left side:
Picture 4 right side:
Picture 5 back (donorarea):

Any remarks