Hair Transplant / Virtual Test

Are you a good candidate for a Hair Transplant?

Virtual test and consultation to find out if you are a good candidate for a Hair Transplant or other therapies to resolve your hair loss.

All information supplied is confidential.

Through this form, you will obtain all the information necessary via telephone or email if you are an ideal candidate for a Hair Transplant or other possible therapies to resolve your hair loss.

This virtual test does not attempt to replace informed medical advice and you should not take any action before consulting with a health professional.

IMPORTANT

• All information is confidential.
• Personal data is collected in this virtual consultation is only used to respond to it.
• Your data will be used only to receive the information you have requested, in accordance the law of the Data Protection Act 15/1999, of December 13, which refers to the protection of personal data (Act). In no case will be transferred this data to third parties or market to them, without their express permission. You can always exercise their right of access, opposition, rectification and / or cancellation thereof, in accordance with the provisions of current legislation on data protection. The data will be verified and any requests that contain false or misleading data will be discarded. View Privacitat Policy

The fields marked with * are obligatory, if you fail to complete any of the obligatory fields the SEND box will not activate.

 

Step 1 of 6

PERSONAL DETAILS

Name: (*) Surname: (*)
Age: (*) Gender: (*)
Address: (*) Town: (*)
Postcode: (*) Country: (*)
E-mail: (*) Telephone: (*)

Step 2 of 6

HISTORY

At what age did you start to lose your hair? (*) Years
Has it been increasing since it began?(*)
Yes No
Has it stabilised over time?(*)
Yes No If you are female, which of these images reflects your baldness?

Type 1

Type 2

Type 3

Type 4

Type 5

Type 6

Type 7

If you are male, which of these images reflects your baldness?

Type I

Type II

Type III

Type IV

Type V

Type VI

Type VII

Are there others with the same problem in your family? Yes No
In the affirmative, indicate in each case the age and type of baldness according to the above images.

Father	Mother
Type: Tipo I Tipo II Tipo III Tipo IV Tipo V Tipo VI Tipo VII	Type: Tipo 1 Tipo 2 Tipo 3 Tipo 4 Tipo 5 Tipo 6 Tipo 7
Age:	Age:
Paternal Grandfather	Paternal Grandmother
Type: Tipo I Tipo II Tipo III Tipo IV Tipo V Tipo VI Tipo VII	Type: Tipo I Tipo II Tipo III Tipo IV Tipo V Tipo VI Tipo VII
Age:	Age:
Maternal Grandfather	Maternal Grandmother
Type: Tipo 1 Tipo 2 Tipo 3 Tipo 4 Tipo 5 Tipo 6 Tipo 7	Type: Tipo 1 Tipo 2 Tipo 3 Tipo 4 Tipo 5 Tipo 6 Tipo 7
Age:	Age:

Step 3 of 6

TREATMENTS FOLLOWED

Have you followed any medical treatment? Vitamins Propecia Minoxidil
If yes, what results were obtained?
Have you had any other type of non-surgical treatment for your baldness? Yes No
If yes, what results were obtained?
Have you had a hair transplant before? Yes No
How long ago?
If yes, what results were obtained?

Step 4 of 6

HAIR TYPE

What is your hair like? Very fine Fine Medium Thick
What colour is your original hair? Red Blonde Chestnut Brown Black
Do you have grey hair?(*) Yes No
Is it totally white?(*) Yes No
Do you consider the thickness of your hair on the nape of your neck important?(*) Yes No
What type of hair do you have?(*) Greasy Normal Dry Dandruff

Step 5 of 6

HAIR CARE

How often do you wash your hair? What type of shampoo do you use?
Do you use other hair care products? Yes No
If yes, which ones and with what frequency?

CURRENT HEALTH

Do you suffer from any chronic illness?(*) Yes No
If yes, which one?
Are you taking any medication?(*) Yes No
If yes, which one?
Are you allergic?(*) Yes No
If yes, what to?
Do you smoke?(*) Yes No

Step 6 of 6

DECISION-MAKING, PERSPECTIVES, QUERIES AND QUESTIONS

If you are thinking of having a Hair Transplant, when would you like to have the surgery?
What questions and queries do you have?

PHOTOGRAPHS

In order for a precise evaluation, you must send 3 JPG photographs with maximum of 500kb each.
Photo facing the front with head slightly inclined forwards: (*)
Side photo: (*)
Photo of the crown of the head: (*)

I authorise the Tricolaser S.L. Clinical Capillary and Cosmetic Institute to send to the email address facilitated publicity and promotions regarding the treatments performed and I have read and accept the Privacy Policy about Data Protection.

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