Özlem Biçer will evaluate your form and we will contact you.
How long have been having hair loss?
What are the reasons for hair loss?
Did you suffer from a systematic medical condition?
Did you ever had a medical operation?
Do you smoke?
YesNo
Do you consume alcohol?
YesNo
Are you on any medication?
YesNo
Are you alergic to any medication or anaesthesia?
YesNo
Do you have hair loss in your family?
YesNo
Please upload pictures of your head from the front, back, side and from above: