Personal Details * Mandatory Name* Surname* Gender* MaleFemale Phone Email* Age* Address How did you hear about Clinica Capelli? Transplant details Preferred method of extraction* ---long hairshort hair Have you had hair transplant surgery before? YesNo Have you used Propecia, Proscar, Finasteride? never usedstopped using more than 6 months agostopped using more than 2 months agocurrently using Have you used Rogaine, Regaine, Minoxidil? never usedstopped using more than 6 months agostopped using more than 2 months agocurrently using Approximate date you would like to have your transplant? E.g.: Spring 2018 Tell us your hair loss story Tell us your hair restoration goals. Photo upload Upload Photo Instructions Ensure the room is evenly light and bright. This is best accomplished in the daytime using natural light. Do not use a flash! It obscures the scalp. If you think you need a flash, you need a brighter room. File Jpg, 3mb per image at maximum, images must be at maximum 1900x1900px Front Photo* - Choose a file Back Photo* - Choose a file Side Photo* - Choose a file Top/Crown Photo* - Choose a file I agree By clicking "I agree" you are allowing Clinica Capelli to provide an accurate estimate about your case, based on the photo's you provide. Your Photo's will be private and secure and will not be used without your permission.