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Online Diagnosen
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Online Diagnosen

Online Diagnosen
By completing this Online Diagnosis form, you will be providing a dedicated DHI Consultant with the pertinent information needed about you and your hair loss history to formulate a hair restoration therapy designed specifically for you. You will be contacted by email within 48 hours of sending this form.


Contact Information

First Name
Last Name  
     
 
City
State / Province
Country
     
 
Address
Zip Code
Email
     
 
Day Phone
Evening Phone
Mobile Phone
     
           
Sex Age
Profession
   Male     Female
 
 
Hair Type
Hair Colour
Hair Texture
Hair Type
  Thin
Medium
Thick 		  Straight
Wavy
Curly
Is there a family history of hair loss?
  Yes    No
At what age did you begin to notice a change in your hairline?
  Less than 20     21-30     31-40     41-50     Over 50
Baldness pattern?
  Class 1   Class 2   Class 3   Class 4   Class 5   Class 6
       
   
The following questions are optional and are intended make the follow-up to your online diagnosis more thorough and assist in making an informed diagnosis for your hair restoration procedure.
 
General Information

 I would like Session information about:
  Your minimally-invasive DHI hair restoration procedure
Other non-invasive options for my hair restoration
      
I would like information on scheduling a Session:
      Now                        Within two months
      Within six months   
   
Background Information

 What would you like to achieve with hair transplants (for example: restore the front hairline, mid-scalp, back, or perhaps your entire balding area)?
 
Have you ever consulted with a doctor about a hair transplant?
  Yes    No  
 
What hair transplant treatment, if any, was recommended?
 
 
Have you undergone a surgical hair restoration?
  Yes    No
 What type of restoration procedure was performed?
 
Has your hair loss problem been treated with any of the following?
  Rogaine:           No    Past    Present
Saw Palmetto:   No    Past    Present
Propecia:          No    Past    Present
Other:              No    Past    Present

If other please indicate here:
 
Receiving Information

 Would you like to be notified of the next DHI Informational Seminar being held nearest you?
  Yes    No
If ‘Yes’ are you interested having a Consultation at the same day?
 
Language Preference
   English     Greek     German
   
How did you find us?
 
Types of Consultation

 DHI offers four different Consultation formats:
  Live consultation through Web Camera (installed and operational on your computer)
By telephone:
      Please advise the best day and time for us to contact you
     
In person at the nearest DHI clinic:
     
     
By email (you will need to provide our consultant with photos of your potential hair implant area)
Additional information you may wish to provide will be helpful.
 
 
 
Pictures

 Please provide up to three photos (maximum 500kb per photo in .jpg format) to assist in your diagnosis.
 
Photo 1:
 
Photo 2:
 
Photo 3:

 

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