Consultation Form

Hair Transplant 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.
In which of the categories below do you belong?
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Field is required!
Field is required!
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For illustration purposes, we need some photos of your hair
(max 5 MB / photo)
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Field is required!
A photo showing your face from the front
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Field is required!
A photo showing your profile
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Field is required!
A photo showing the back of your head
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Field is required!
How old are you?
You need to be older than 18
You need to be older than 18
What is your origin?
  • - select a option -
  • European
  • Arabic
  • Asiatic
  • African
  • North American
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Field is required!
What is your hair color?
  • - select a option -
  • Blonde
  • Brown
  • Red
  • Black
  • Grey
  • White
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Field is required!
What is your hair type?
  • - select a option -
  • Straight
  • Wavy
  • Curly
  • Very Curly
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Field is required!
Do you have a family history of hair loss?
  • - select a option -
  • No
  • Yes
Field is required!
Field is required!
Have you already consulted another doctor?
  • - select a option -
  • No
  • Yes
Field is required!
Field is required!
If yes, which of these methods were proposed to you?
Field is required!
Field is required!
Have you ever had any other hair transplantation?
  • - select a option -
  • No
  • Yes
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Field is required!
If yes, which method was used?
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Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
  • - 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
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
How did you hear about us?
  • - select a option -
  • Other client
  • Medical abstracts
  • TV
  • Radio
  • Newspaper
  • Other
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Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
You must agree to the Terms & Conditions and our Privacy Policy to continue.
You must agree to the Terms & Conditions and our Privacy Policy to continue.
Swiss Luxury Clinic Hair Transplants

Make an appointment

Please fill in the information requested below so we can contact you with more information regarding your questions on hair loss, hair transplantation and hair restoration.

+41 (0) 434883707 [email protected]