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69 rue de la Tour
75016 Paris
Tel : 01 40 72 89 10

Prior to the consultation in Paris, you can receive a free estimate of your surgery (only for men). You just have to fill up the form below and send it back by fax to this number: +33- 1 40 72 51 55 or by regular mail once it has been printed along with latest pictures of your head (front, outline, top and back). A discreet and confidential mail will be sent to you.

YOUR CUSTOMIZED ESTIMATE (only for men)
If you wish a surgery's cost temporary estimate, you can answer the form below: this does not constitute a medical consultation.
(IMPORTANT: this estimate will be sent back to you at the earliest. It will be established according to the answers given by you in the form.
This estimate does not constitute a firm and definitive quote which can be done only after a detailed examination of your scalp during the consultation at the Center. Your answers are confidential and their sole purpose is to establish a customized estimate. You are entitled to access, modify, change or delete these personal data (as stated in Schedule 34 Information Technology and Freedom Act 6-01-1978 - Art. 34 de la loi Informatique et Liberté du 6 janvier 1978).


INFORMATIONS

Name :
Surname :
Mail :

Age years old.
At what age your hair started falling? years old.

Do you have any relative having receding hairline or baldness?
yes no

According to you, has your baldness stabilized for the last one year?
yes no

Do you face any problem when you brush your hair?
yes no

According to you, has your appearance changed during the last one year?
yes no

Do you wear a capillary prosthesis?
yes no

If the answer is yes, your capillary prosthesis is fixed by :
Glue Plait Clips


YOUR HAIR CUT

You do your hair :

Sideward with a parting? Frontward? Backward? Other ?

Do you have hair remaining on the top of the head?
yes no

If the answer is Yes, the hair on the top of the head are:
Very short (less than 2 cm long?) Average length (between 2 & 5 cm) Long (more than 5 cm in length)

What is the colour of your hair?

Black Dark Brown Light Brown
Blond Gray White

What is the texture of your hair?
Straight With waves Curly Frizzy




YOUR BALDNESS PATTERN

You are balding:
Front Back (tonsure) the full skull

Do you pull down a hair lock to reduce your baldness?
yes no


CHOOSE YOUR BALDNESS PATTERN :
# 1
# 2
# 2A
# 3
# 3A
# 3V
# 4
# 4A
# 5
# 5A
# 6
# 7

Your crown (hairy area on the back and on the side of your head):
According to you and with the drawing below, what is the measurement of your crown?

More than 10 cm height
Between 8 and 10 cm
Between 6 and 8 cm
Less than 6 cm



According to you, is your crown hair thick enough?
yes no

Are your crown hairs more than 2 cm in lenght?
yes no

You wish to treat in priority:

The anterior area of your baldness The posterior area of the baldness The whole baldness

If possible and for convenience reason, you wish to treat your baldness:
In one single session In several session

Did you understand properly the difference between micrografting and ultra micrografting techniques?
yes no

Remarks & Comments :

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