Hair Loss Treatment Consultation

For PRP, PRF, microneedling or combined hair loss treatments. Please complete the form honestly before your appointment.

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Hair loss online form

Client details and suitability

Do not fill this out:

Full name Date of birth Contact number Email address Address How did you hear about us? Main concern regarding your hair When did you first notice hair loss or thinning?

Which areas are affected? Front hairline Top/crown Temples Whole scalp Other

Has anyone in your immediate family experienced hair loss? If yes, please specify relationship Have you had any previous treatments for hair loss? If yes, please list what you had, when and results Do you currently use any products for your hair/scalp? If yes, please list products

Medical history

Please answer Yes or No. This helps the clinic check whether treatment is safe and suitable.

Do you have any bleeding disorders or blood clotting problems?Are you taking any blood-thinning medication such as warfarin, aspirin or clopidogrel?Do you have diabetes?Do you have a history of cancer or current cancer treatment?Do you have any autoimmune conditions?Do you have any infections, skin conditions or scars on your scalp?Are you pregnant, breastfeeding or planning to become pregnant?Do you have allergies to any medications or products?Have you had any major surgery in the last 6 months?Do you smoke or drink alcohol regularly? Please list any other medical conditions or medications

Treatment type PRP PRF Microneedling Combined treatment

I confirm that I have read and understood the treatment information, possible risks, expected results and aftercare guidance. I confirm the information provided is true and I consent to Angel Hands Aesthetics reviewing this consultation form.

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Angel Hands AestheticsPrivate appointment-only clinic • Dulwich