"
*
" indicates required fields
Step
1
of
9
11%
PLEASE CHOOSE YOUR GENDER!
PLEASE CHOOSE YOUR GENDER!
*
Female
Male
HOW WOULD YOU DESCRIBE YOUR HAIR LOSS?
HOW WOULD YOU DESCRIBE YOUR HAIR LOSS?
*
Receding hairline
Light hair
Slightly bald
HOW WOULD YOU DESCRIBE YOUR HAIR LOSS?
HOW WOULD YOU DESCRIBE YOUR HAIR LOSS?
*
Receding hairline - moderate
Receding hairline - severe
Crown - moderate
Crown - severe
Bald
Hair transplant method
Hair transplant method
*
DHI
Saphirre FUE
Learn more
Select hotel
Hotel
*
Normal - 2 minutes from the clinic
Deluxe - 15 minutes from the clinic
SINCE WHEN DO YOU SUFFER FROM HAIR LOSS?
SINCE WHEN DO YOU SUFFER FROM HAIR LOSS?
*
1-3 years
3-6 years
6-10 years
More than 10 years
HOW BAD DO YOU FEEL ABOUT YOUR CURRENT HAIR SITUATION?
HOW BAD DO YOU FEEL ABOUT YOUR CURRENT HAIR SITUATION?
*
Really bad
Bad
Average
Not that bad
WHEN WOULD YOU LIKE TO HAVE THE TREATMENT DONE?
WHEN WOULD YOU LIKE TO HAVE THE TREATMENT DONE?
*
As soon as possible
In the next 3 months
In the next 12 months
I only want information
ALMOST FINISHED...
Who should we send the analysis to?
First Name
*
Last Name
Email
*
Phone
*
Preferred language
*
English
Nederlands
Español
Portuguese
NL
EN
ES
Phones numbers
+1 888-337-3209
+1 888-337-3209
+1 888-337-3209
