AURA Hair transplantation information form

1

Your detailsLet us know who you are

Please enter your name

Please enter your email

Phone number

Date of birth

2

At what age did you notice your hair loss?

3

How long has your hair loss pattern stabilised?

4

Please look at this image and decide which one best represents your pattern of hair loss.

5

Which image best represented your pattern of hair loss?

6

Please describe your family history of hair loss

8

Do you have any of the following medical conditions?

Diabetes

Thyroid disease

Alopecia areata

Keloid or hypertrophic scarring

Dermatological conditions