Union Hospital

Free Online Diagnosis Form

Please read this first carefully:
By completing the free Online Diagnosis form, you will be providing a dedicated DHI doctor 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 / telephone as soon as possible.

1.	Contact Information
	First Name	Last Name

	City	State / Province	Country

	Address	Zip Code	Email

	Day Phone (Please State )	Evening Phone	Mobile Phone (Please State )

	Sex (Please State )	Age (Please State )	Profession
	Male Female

2.	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.

3.	General Information
	I would like Session information about:
	Pre-procedure preparation Post-operative care and recovery Others (Please state: )





4.	Background Information
	What would you like to achieve with Union DHI Hair Centre (for example: restore the front hairline, midscalp, back or perhaps your entire balding area)?

	Have you ever consulted with a doctor about a hair translant?
	Yes No
	Have you been recommended any hair transplant treatment?
	Yes ( recommended number of hairs: ) No
	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:

5.	Receiving Information
	Do you wish to receive our information on health issues and our promotional activities / special offers through email regularly? Yes No

	How did you find us?