Consultation Form

Use our free tool for a first assessment of your own hair loss issue by our medical staff.

With our hair loss assessment tool you can provide significant information to us concerning your hair loss problem. Please complete and submit the questionnaire, and we will contact you with an initial diagnosis by one of our specialist doctors. This assessment is free of charge and does not in any way oblige you to book a hair transplantation session at the Swiss Luxury Clinic.

Step 1 of 4: Your hair loss type
Fields marked with * are mandatory.
In which of the categories below do you belong?*
For illustration purposes, please upload a picture of your hair (max. 5 MB / photo): a picture showing your face from the front
Upload your photo...
a picture showing your profile
Upload your photo...
a picture showing the back of your head
Upload your photo...
Step 2 of 4: Your hair loss history
Fields marked with * are mandatory.
How old are you? *
What is your origin? *
  • - select a option -
  • European
  • Arabic
  • Asiatic
  • African
  • North American
  • South American
What is your hair colour? *
  • - select a option -
  • Blonde
  • Brown
  • Red
  • Black
  • Grey
  • White
What is your hair type?
  • - select a option -
  • Straight
  • Wavy
  • Curly
  • Very curly
Do you have a family history of hair loss? *
  • - select a option -
  • No
  • Yes
Have you already been informed by another doctor? *
  • - select a option -
  • No
  • Yes
If yes, which of these methods did he propose to you?
Have you ever had any other hair transplantation? *
  • - select a option -
  • No
  • Yes
If yes, which method was used?
Step 3 of 4: Your medical details
Fields marked with * are mandatory.
Please answer all the medical questions below. It is important to be very thorough with your replies, listing any medical or psychological history, medication and allergies, as the possibility to carry out any hair transplantation procedure may be influenced by these conditions.Patients under medication should advise their doctor before their hair transplantation treatment. The doctor may cancel or postpone your hair transplantation treatment if he or she does not consider you to be an adequate candidate.
Name of your doctor:
Do you smoke? *
  • - select a option -
  • No
  • Yes
Have you had, or been treated for any of the following:
Any condition not listed above?
Are you pregnant? *
  • - select a option -
  • No
  • Yes
Do you take the Pill? *
  • - select a option -
  • No
  • Yes
Any medication not listed above?
Have you got any scarring problems (please define if applicable)?
How would you describe your general health – including diet and fitness?
Do you have any problems with your eyes eg. dry eyes:
Have you ever shown any allergic reaction to general or local anaesthetic treatment? *
  • - select a option -
  • No
  • Yes
Step 4 of 4: Your personal details
Fields marked with * are mandatory.
First name *
Last name *
E-mail *
Address
Postal code
Town / city
Country *
  • - select your country -
  • Åland Islands
  • Afghanistan
  • Albania
  • Algeria
  • American Samoa (US)
  • Andorra
  • Angola
  • Antigua and Barbuda
  • Argentina
  • Armenia
  • Australia
  • Austria
  • Azerbaijan
  • Bahamas
  • Bahrain
  • Bangladesh
  • Barbados
  • Belarus
  • Belgium
  • Belize
  • Benin
  • Bermuda (UK)
  • Bhutan
  • Bolivia
  • Bosnia and Herzegovina
  • Botswana
  • Brazil
  • Brunei
  • Bulgaria
  • Burkina Faso
  • Burma (Myanmar)
  • Burundi
  • Cambodia
  • Cameroon
  • Canada
  • Cape Verde
  • Central African Republic
  • Chad
  • Chile
  • China
  • Colombia
  • Comoros
  • Congo, Democratic Republic of the
  • Congo, Republic of the
  • Cook Islands (NZ)
  • Costa Rica
  • Croatia
  • Cuba
  • Cyprus
  • Czech Republic
  • Denmark
  • Djibouti
  • Dominica
  • Dominican Republic
  • East Timor (Timor-Leste)
  • Ecuador
  • Egypt
  • El Salvador
  • Equatorial Guinea
  • Eritrea
  • Estonia
  • Ethiopia
  • Falkland Islands (UK)
  • Faroe Islands (Denmark)
  • Fiji
  • Finland
  • France
  • French Guiana
  • French Polynesia (France)
  • Gabon
  • Gambia
  • Georgia
  • Germany
  • Ghana
  • Gibraltar (UK)
  • Greece
  • Greenland (Denmark)
  • Grenada
  • Guam (US)
  • Guatemala
  • Guernsey (UK)
  • Guinea
  • Guinea-Bissau
  • Guyana
  • Haiti
  • Honduras
  • Hong Kong (China)
  • Hungary
  • Iceland
  • India
  • Indonesia
  • Iran
  • Iraq
  • Ireland
  • Isle of Man (UK)
  • Israel
  • Italy
  • Ivory Coast
  • Jamaica
  • Japan
  • Jersey (UK)
  • Jordan
  • Kazakhstan
  • Kenya
  • Kiribati
  • Korea, North
  • Korea, South
  • Kosovo
  • Kuwait
  • Kyrgyzstan
  • Laos
  • Latvia
  • Lebanon
  • Lesotho
  • Liberia
  • Libya
  • Liechtenstein
  • Lithuania
  • Luxembourg
  • Macau (China)
  • Macedonia
  • Madagascar
  • Malawi
  • Malaysia
  • Maldives
  • Mali
  • Malta
  • Marshall Islands
  • Mauritania
  • Mauritius
  • Mayotte (France)
  • Mexico
  • Micronesia, Federated States of
  • Moldova
  • Monaco
  • Mongolia
  • Montenegro
  • Morocco
  • Mozambique
  • Namibia
  • Nauru
  • Nepal
  • Netherlands
  • New Caledonia (France)
  • New Zealand
  • Nicaragua
  • Niger
  • Nigeria
  • Niue (NZ)
  • Norfolk Island (Australia)
  • Northern Mariana Islands (US)
  • Norway
  • Oman
  • Pakistan
  • Palau
  • Palestinian territories
  • Panama
  • Papua New Guinea
  • Paraguay
  • Peru
  • Philippines
  • Pitcairn Islands (UK)
  • Poland
  • Portugal
  • Qatar
  • Réunion (France)
  • Romania
  • Russian Federation
  • Rwanda
  • São Tomé and Príncipe
  • Saint Helena, Ascension and Tristan da Cunha (UK)
  • Saint Kitts and Nevis
  • Saint Lucia
  • Saint Pierre and Miquelon (France)
  • Saint Vincent and the Grenadines
  • Samoa
  • San Marino
  • Saudi Arabia
  • Senegal
  • Serbia
  • Seychelles
  • Sierra Leone
  • Singapore
  • Slovakia
  • Slovenia
  • Solomon Islands
  • Somalia
  • South Africa
  • South Sudan
  • Spain
  • Sri Lanka
  • Sudan
  • Suriname
  • Svalbard and Jan Mayen (Norway)
  • Swaziland
  • Sweden
  • Switzerland
  • Syria
  • Taiwan
  • Tajikistan
  • Tanzania
  • Thailand
  • Togo
  • Tokelau (NZ)
  • Tonga
  • Trinidad and Tobago
  • Tunisia
  • Turkey
  • Turkmenistan
  • Tuvalu
  • Uganda
  • Ukraine
  • United Arab Emirates
  • United Kingdom
  • United States
  • Uruguay
  • Uzbekistan
  • Vanuatu
  • Vatican City
  • Venezuela
  • Vietnam
  • Wallis and Futuna (France)
  • Western Sahara
  • Yemen
  • Zambia
  • Zimbabwe
Profession
Telephone *
Your message
What budget have you planned for your hair treatment? *
How did you hear about us?
  • - select a option -
  • Other client
  • Medical abstracts
  • TV
  • Radio
  • Newspaper
  • Internet
  • Other
Please be aware that our assessment can only be approximate and cannot replace any personal consultation of a doctor. Swiss Luxury Clinic will protect the privacy of all information provided and will not pass on your details to any third parties, including hospitals, clinics, or doctors, without your prior consent.