Dear Visitor, the Online Consultation Form allows you to send your hair condition details for advice. Please fill in the form and send it to us. Once received, our patient coordinators in conjuction with our doctors will reply with an in depth study and diagnosis to your hair loss problem. You can also send us your digital photos by a separate e-mail. This will give us the opportunity to give a better recommendation for your  hair condition. Thanks for your interest in our clinic.  

Personal Information

Name* Surname*

Date of Birth* Sex* Profession Select Sex Male Female

Country* City State / Province Post Code Select Country Cyprus Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Canton and Enderbury Islands Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire Croatia (Hrvatska) Cuba Cyprus Czech Republic Democratic Yemen Denmark Djibouti Dominica Dominican Republic Dronning Maud Land East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France France, Metropolitan French Guiana French Polynesia French Southern Territories F.Y.R.O.M. Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-bisseu Guyana Haiti Heard and Mc Donald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic of) Iraq Ireland Israel Italy Ivory Coast Jamaica Japan Johnston Island Jordan Kazakstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Midway Islands Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles Neutral Zone New Calidonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pacific Islands Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Island Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda S. Georgia and S. Sandwich Isls. Saint Lucia Saint Vincent/Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia (Slovak Republic) Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka St. Helena St. Kitts Nevis Anguilla St. Pierre and Miquelon Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syran Arab Republic Taiwan Tajikistan Tanzania, United Republic of Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Minor Outlying Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Pacific Islands Upper Volta Uruguay Uzbekistan Vanuatu Vatican City State Venezuela VietNam Virgin Islands, British Virgin Islands, Unites States Wake Island Wallis and Futuma Islands Western Sahara Yemen Zaire Zambia Zimbabwe

Contact day phone* Contact Evening phone Email*

Hair Condition

At what age did you begin to experience hair loss? Select Less than 20 20-25 26-30 31-35 36-40 Over 41

Baldness Pattern for Men:*

Class 1 Class 2 Class 3 Class 3V Class 4 Class 5 Class 6 Class 7

Baldness Pattern for Women:* Grade 1 Grade 2 Grade 3

Treatment Requirement

What are you interested in?* Select Information Hair Loss Treatment Hair Transplant

If you are interested in hair transplant, which area are you primarily interested in recovering?

Front Hairline Crown Mid Scalp

Do you have a preferred method for your hair restoration? To be recommended No STRIP FUE Body Hair FUE

When are you interested to carry out your Hair Transplant?* Select As soon as possible Next two months 2 months to 6 months 6 months - 1 year Over 1 year

Are you presently taking Propecia? Select Yes No

If yes, for how long?

Are you presently taking Minoxidil? Select Yes No

If yes, for how long?

Have you ever had surgical hair restoration performed? Select Yes No

If yes: How many sessions? When was the last session?   How many grafts?   In which clinic was the surgery carried out?

General Information

How did you hear about us?

Friend Magazine/Newspaper, Which? Radio. Which?   Search Engine. Which?   Link from other website. Which?   Others. Please specify

How do you prefer to be contacted? Select Telephone Email Either

If by phone, please advice most convinient date and time for you to be contacted Date Time What language do you prefer to have your e-mails replied in? Select Greek English Either General Comments: If you would like to send your photos, please e-mail them to info@hdc.com.cy