Personal Information

    Medical History

    A. General Health Questions

    YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo YesNo

    B. Hair Loss History

    YesNo YesNo YesNo YesNo

    Hair Transplant Procedure Information

    FUE (Follicular Unit Extraction)DHI (Direct Hair Implantation)Not Sure, Need Consultation YesNo

    Consent & Acknowledgment

    A. Procedure Consent

    I Agree

    B. Photo & Data Consent (Optional)

    YesNo YesNo
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