What are your hair restoration goals?

Stop further Hair loss

Regrow loss Hair

Have you had any hair transplants? Please provide details
(i.e., dates and types)

Yes

No

If Yes Please provide details here

Any Medical Problem –

Yes

No

If Yes then these options

Past medical History

High Blood Pressure

Heart Attack

Psychiatric Diagnosis

Asthma

Hepatitis

Heart Disease

Chest Pain

Bleeding Problems

Cancer

Emphysema

Heart Failure

Diabetes

Liver Disease

HIV or AIDS

Stomach Problems

Seizures

Kidney Disease

Gastric Reflux

Stroke

Other

None

Family History of hair loss (Both Father & Mother Side)

Yes

No

Past Surgical History

Yes

No

If Yes Please provide details here

Significant Medical Problem in Family

Yes

No

If Yes then these options

History of Allergies

Yes

No

If Yes Please provide details here

Any Medications & Therapies taken for hair loss

Yes

No

If Yes Please List medical supplements

1.

2.

3.

4.

Photo Uploads

Instructions for Photos:

Submit one different photo for each of the four views (Front, Side/Angle, Top, and Rear)
Photos with dry hair only
Include your entire head. You may block out your face, but very close-up photos are not useful. The doctor needs to see the overall pattern of your hair loss
Click below to upload your photos

Click Here

Reasons for Inquiry

You may select more than one option:

First Name ^*

Last Name ^*

Enter Email ^*

Confirm Email ^*

Phone Number (Add Country Code) ^*

How Would You Prefer To Be Contacted?

Phone

Email

Video Call

Skype

FaceTime

Imo

City

State / Province / Region

ZIP / Postal Code

Country

Date of Birth

Age

Gender

How did you first hear about Saraswat Hospital

Any Comments (Optional)

“International Standards and Affordable Cost”

Online Consultation for Hair Loss

Hair Loss Info

What are your hair restoration goals?

Have you had any hair transplants? Please provide details
(i.e., dates and types)

If Yes Please provide details here

Any Medical Problem –

Family History of hair loss (Both Father & Mother Side)

Past Surgical History

If Yes Please provide details here

Significant Medical Problem in Family

If Yes then these options

History of Allergies

If Yes Please provide details here

Any Medications & Therapies taken for hair loss

If Yes Please List medical supplements

Photo Uploads

Instructions for Photos:

Front View^*

Side/Angle View^*

Top View^*

Rear View^*

Reasons for Inquiry

You may select more than one option:

Contact Us

Saraswat Hospital (A Complete Hair Transplant, Laser, Cosmetic Surgery & Plastic Surgery Hospital)

“International Standards and Affordable Cost”

Online Consultation for Hair Loss

Hair Loss Info

What are your hair restoration goals?

Have you had any hair transplants? Please provide details(i.e., dates and types)

If Yes Please provide details here

Any Medical Problem –

If Yes then these options

Family History of hair loss (Both Father & Mother Side)

Past Surgical History

If Yes Please provide details here

Significant Medical Problem in Family

If Yes then these options

History of Allergies

If Yes Please provide details here

Any Medications & Therapies taken for hair loss

If Yes Please List medical supplements

Photo Uploads

Instructions for Photos:

Front View*

Side/Angle View*

Top View*

Rear View*

Reasons for Inquiry

You may select more than one option:

Contact Us

Saraswat Hospital (A Complete Hair Transplant, Laser, Cosmetic Surgery & Plastic Surgery Hospital)

Have you had any hair transplants? Please provide details
(i.e., dates and types)

Front View^*

Side/Angle View^*

Top View^*

Rear View^*