Farjo Hair Institute | Online Assessment Form

Complete and submit the following form for a confidential online assessment.

Please enter as much information as possible so we can accurately assess your needs.

*Denotes a required field

Hair Loss Details

Age when hair loss started?*

Is the hair loss now stable?*

How long has it been stable?

Family history of hair loss?*

Current Hair Treatments?*

Previous hair surgery?*

Norwood Hair Loss Scale:

Please upload an image file (jpg, png, jpeg or pdf) no larger than 4MB

Top left of the head photo:*

Top right of the head photo:*

Back of the head photo:*

Front of the head photo:*

How did you hear about us?

Any other information?

First Name:*

Last Name:*

Date of Birth:*

Email Address:*

Telephone:*

Address line 1:

Address line 2:

City:*

Postcode:

Country:*