Hair Translant Australia | Australian Institute of Hair Restoration

1.Your Age:

2.Your Gender:

3. Your natural hair colour is?

Black / Dark Brown

Med Brown

Gray

Light Brown / Blond / Red

4. Which best describes the texture of your hair?

straight

wavy

curly

5. What is the texture of your hair?

fine

medium

thick

6. Click on the image that matches your hair loss condition when your hair is wet.

7. What are your expectations from hair transplantation (restore the front hairline,
mid scalp, back, or your entire balding area)?

8. Have you used any of these oral & topical medications for your hair loss?

Rogaine	Past	Present	Never
Saw Palmetto	Past	Present	Never
Propecia	Past	Present	Never
Other	Past	Present	Never

9. Feel free to send your comments or questions:

Note - This form and any reply to it does not take the place of an actual in person consultation. It is merely intended to provide us with an initial idea of your condition and goals. With this information we can then
give you an informed reply.

*First Name(required):

*Last Name(required):

Check here if you do NOT
want any information mailed to
your Street address.

*Street Address Line 1:
(required)

Street Address Line 2:

*City(required):

*State/Province(required):

*Post Code(required):

*Country(required):

Day Phone:

*Email Address(required):

I want to be on the private
newsletter list.

I prefer to be contacted by:

phone

either

Please attach photo of your
hair loss area (Up to 2 MB)

Security Code:

Change Image

Write the code in the image above: