Patient Registration
Complete the form below to register for a consultation
Personal Information
Full Name
*
Email Address
*
Phone Number
*
Date of Birth
*
Gender
*
Select Gender
Male
Female
Other
Civil Status
Select Status
Single
Married
Divorced
Widowed
Nationality
Select Nationality
Philippines
United States
Canada
United Kingdom
Australia
Other
Religion
Select Religion
Catholic
Protestant
Muslim
Hindu
Buddhist
Other
Occupation
Contact Information
Address
City
State/Province
ZIP/Postal Code
Emergency Contact
Emergency Contact Name
Emergency Contact Number
Relationship
Select Relationship
Spouse
Parent
Sibling
Friend
Other
Medical History
When did you first notice signs of hair loss?
How would you describe your hair loss?
Select Description
Ongoing
Steady
Which areas are your concern?
Hairline
Mid scalp
Crown
Eyebrow
Eyelash
Facial Hair
Hair loss treatments you used/currently using?
Minoxidil
Finasteride
Dutasteride
PRP
LLLT
NOA
Other treatments (please specify)
Medications currently taking
Have you had a consultation with any other hair restoration group?
Yes
No
Have you had a previous hair transplant procedures?
Yes
No
Do you have any other medical conditions?
Hormonal imbalance
Thyroid Problem
Nutritional Deficiency
Diabetes Mellitus
Allergies
Autoimmune Disease
Cancer
Does anyone in the family suffer hair loss? (e.g., Mother, Father, Siblings, Other)
Lifestyle Factors
Are you undergoing any hormone therapy?
Do you smoke?
For Women Only
Women-specific Information
Is your menstruation regular?
Do you take any birth control pills?
Are you currently pregnant?
Are you currently breastfeeding?
Date of last pregnancy
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