Name and surname *
Email *
Phone (include international prefix)*
Country of residence *
Age *
How do you prefer us to contact you?? *Phone callWhatsAppE-mail
What time do you prefer to contact you? *Morning (11 a 14h)Midday (14 a 17h)Evening (17 a 19h)

SexMaleFemale

How did you know about us?FamilyInternetSocial NetworkMediaBest Hair ClinicsAsesoramiento capilar (Michael & Towers)Hair Transplant NetworkBald Truth TalkOthers

Do you have history of baldness in the family?NoFatherMotherUncles/AuntsGrandparents

Do you use some of this medecine?FinasterideFinastopicDutasterideMinoxidil

How long have you been taking those medicines?

What service do you need?Hair transplantHair treatment (PRP/PRF or mesotherapy)

Did you have a previous hair transplant?YesNo

Which zone do you want to recovery?Fronthair entrancesMiddle zoneVertexEyebrowsBeardScars

Where would you like to perform the possible hair transplant?Madrid (Spain)Mexico

Query:

Please, we need some photos like we show you below.

Attach them in a mail to info@drespinosacustodio.com. Please, fill the email subject with 'Diagnosis' followed by your name and surname.

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