Consultation form

If you would like to receive an assessment of your personal treatment costs, we kindly ask you to fill in this online consultation form. By filling in the queries below as accurately as possible, you unable us to make a rough estimation of your treatment costs.

Fields marked with an asterisk (*) are mandatory as we cannot establish an accurate assessment without this information.

Please bear in mind that this online consultation form can under no circumstances replace a live consultation.

Personal information

Title *

First name *

Last name *

Street no. box *

Postal code *

City *

Country *

Year of birth (example : 1980) *

Phone number *

Cell phone number *

E-mail *

Which zones would you like to have treated?

Welke zones wenst u te laten behandelen?

Hair situation (pictures)

To give Dr. Feriduni an accurate perspective of your actual hair situation, we kindly ask you to send in good quality pictures according to our photo guidelines

A picture of the hairline *

By seeing the existing or non-existing hairline, Dr. Feriduni could visualize the possibilities of the new hairline design and how it would define the patient’s facial proportions. Drawing a draft of the desired hairline on the picture could give Dr. Feriduni an image of your anticipations and wishes. Please note that your hair needs to be pulled or combed backwards to have an accurate perception of the hair loss in your hairline.

Allowed file types: gif png jpg jpeg.

A picture of the top of the scalp *

By sending a picture of the top of the scalp, Dr. Feriduni will get an overview of the patient ‘s hair loss pattern and of the overall density of the hairs, this will be helpful when he will have to estimate the total number of follicular units.
Please note that it would be ideal to take a picture of the full top view in order to have a good perception of the size of your recipient area.

Allowed file types: gif png jpg jpeg.

A picture of the right or left profile *

The profiles are very important in assessing the needs of our patients. The profiles help us understand the extent of hair loss.

Allowed file types: gif png jpg jpeg.

A picture of the donor area *

This will give Dr. Feriduni the possibility to estimate the yield of available donor hairs and he will be able to evaluate the options of the donor area. This is decisive when choosing the accurate technique for each patient.
Please note that it is important to take a picture of the full donor area so Dr. Feriduni could visualize the entire donor capacity and detect possible miniaturization in the low crown area.

Allowed file types: gif png jpg jpeg.

Extra questions from you

Please do understand that the purpose of this consultation form is to gain information, it can on no account replace a live consultation.