Consultation Form - Divine cosmetic centre, Hair Restoration

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Hair Transplant Consultation Form

Please consider filling out this form as accurately as possible. In the process you will be assisted by my assistant. The information that is given by you will form the basis of the personal consult and also in further treatment planning. Thank you for your interest in undergoing treatment at Divine Cosmetic Surgery, Delhi, India.

Please be assured that all information given by you will be confidential and not be disclosed to anyone. Your pictures will not be shown to anyone or on any website without your prior consent.

*Name :

Age :

Gender :

Permanent Address :

*E-mail :

*Phone :


(Local)	(Permanent)

CLINICAL DETAILS

*Please list concerns . Are you considering Hair transplant or would you like to consider medical managements of hair loss -

*1 :
*2 :
*3 :

*Do you know of the different techniques of hair transplants :

*Do you smoke ?

*Do you have a genetic pattern of hair loss.If so is it similar to your current pattern of hair loss :

*Are you on any medicines for hair loss or otherwise :

*Have you had any surgical procedure before :

*Have you ever had any cardiac intervention, angiography or any other procedure before :

*Are you now on or ever taken any blood thinner medicines – aspirin, acetrome, warfarin etc. :

*Have you ever been diagnosed with Alopecia conditions :

*Have you had any other cosmetic surgery procedure before ? If yes, please give details and when the procedures were done :

*Any previous hospitalistion ?

*Any previous long treatment ?

*Any history of diabetes ?

*Any history of blood clotting, DVT ?

*Have you any known allergies

*Any other details you would like to share with us for a better planning and result :

*Do you wish to be contacted to schedule any further appointments. If so by phone or email :

Hair Transplants

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Hair Transplant

	Procedure
	Pre Procedure Investigations
	Rationale
	Techniques
	Refinements
	Post Transplant Care
	Side Effects
	FUE
	BHT
	Hair Max