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Consultation_form

Consultation Form

Please take a moment to complete all fields and required information in the forms below, including your hair restoration goals and any questions you have. If you have questions or any trouble completing the form, please email us at:
dezireclinicindia@gmail.com or Call to: +91 9222 122 122

Age*
Gender*
Select your hair loss condition according to the grade of baldness*


What are your hair restoration goals and what would you like to achieve for example: restore the front hairline, mid scalp, back, or your entire balding area and high density or camaflouge)? *
At what age did you begin to notice hair loss?*
Have you consulted with a doctor about your hair loss condition?*
With Whom?

What treatment, if any, was recommended?
Have you ever had surgical hair restoration performed?
With Whom?

Have you treated your hair loss with any of the following?
Minoxidil
Finasteride
Do you have any medical issues* ?
What is your family hair loss history?
Do you currently wear a hairpiece?
Please add any additional questions or comments:


Upload Your Photos

 

Please ensure you upload photos that are clear and capture all of the views shown in the examples below:(max-size:1MB, upload in JPEG GIF or JPG format images)

 

 

Picture 1 : Front view
Picture 2 : Top view
Picture 3 : Right view
Picture 4 : Left view
Picture 5 : Back of Scalp


 

Your Contact Information

 

Name*
Email Address*
City*
Phone*
Country*
I prefer to be contacted by:
How did you hear about us?