PRACTICE OF DR. FERIDUNI Hair restoration surgery - picture gallery > ONLINE CONSULTATION It is possible to receive a valid quotation from us through our online consultation. This quotation is based on your present hair situation and on the number of transplants we estimate to be necessary. By filling in the data below as accurately as possible, you can help our team to make a quotation. It is important to know that your data is strictly confident and will only be used in order to make a proper quotation of your hairloss situation. Title Madam Sir Dr. First Name Family Name ADRESS Date of birth Telephone number Cell phone number Email Address Do you wish to speak to one of our contact people?   yes no HAIR SITUATION Hair type European African Asian Hair structure fine medium thick stiff curly frizzy Hair color black brown blonde gray MEDICAL DATA     Do you suffer from, or have suffered from, conditions and/or symptoms that are related to one of the data below: Anemia yes no Disorder of the thyroid yes no Allergies yes no Disease of the vital organs (heart, lungs, kidneys, blood pressure, etc.) yes no Acute illness or operations (during the previous 12 months) yes no If so, which? Do you use any form of medication? yes no If so, which? Do you follow a diet? yes no Have you undergone gynaecological surgery during the previous 12 months? If so, which? hysterectomy ovarectomy other § Do you suffer from stress? yes no HAIR LOSS   Is there a family history of hair loss? yes no Type of hair loss: androgenetic alopecia diffuse hair loss alopecia cicatricialis other Duration of your hair loss: weeks months years   Where is the hair loss? indentations entire hair line crown tonsure diffuse   No hair loss A little hair loss Moderate Much No hair ZONE 1 ZONE 2 ZONE 3 ZONE 4 ZONE 5 ZONE 5V ZONE 6 Which zone do you wish to have treated? indentations entire hair line crown tonsure diffuse other Which technique do you prefer? Follicular Unit transplantation Follicular Unit Extraction Beide Are you presently already treating your hair loss, or have you already treated in the past, with one of the medications below: Propecia yes no   Rogaine yes no   Minoxidil yes no   other yes no To be able to evaluate your hair situation even better, we request that you send us at least three clear pictures of your hair. One picture of the top of the scalp, this gives us an overall view of your hair situation. One picture of the left side of your scalp and one from the right side of your scalp. As soon as we have received your form including the pictures, we will supply you with a quotation with the estimated number of transplants needed. Foto 1 Foto 2 Foto 3 JOBS TERMS & CONDITIONS IMPRINT © DR. BIJAN FERIDUNI 2005 - ALL RIGHT RESERVED. NO PART OF THIS SITE MAY BE REPRODUCED WITHOUT THE PERMISSION OF THE PRACTICE OF DR. FERIDUNI. THE COPYRIGHT OF THE INFORMATION PRESENTED IN THE LINKED WEBSITES IS EXCLUSIVELY RESERVED TO THE PARTY ENTITLED TO THE PAGES CONCERNED.