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Submit Medical History

Complete Your Medical History
Before booking your first consultation, please fill out the Medical History Form.

 

Upload Photos
Take 2 clear photos of your scalp and upload them along with your Medical History Form.

My Medical History

Please complete all the fields.

Birthday
Day
Month
Year
What brings you in today?

e.g: 3 Months, 4 Years

Is the hair loss gradual or sudden?
Wich type are you?

Upload up to 2 pictures

By submitting your medical information and photos, you consent to their use by Dr. Goudelas and the clinic’s medical staff solely for diagnostic and treatment purposes, in accordance with privacy regulations.

All medical history information is handled with strict confidentiality and securely protected in compliance with healthcare privacy regulations.

current hair condition
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