WA Request Hair Transplant - Cocoon Medical Spa

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- Legian
- Ubud
- Canggu

Now open in Legian, Ubud, Canggu, | +62 811-388-815

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PERSONAL DETAILS

Full Name* Date of Birth* Email* WhatsApp Number* Occupation

HAIR LOSS HISTORY

Do you have a family history of hair loss? * When did you first notice hair loss? Which areas are affected?*

Hairline Crown Top/Mid Scalp Donor Area Other

How fast is your hair loss progressing?

PREVIOUS HAIR LOSS TREATMENTS

Have you had or used any of the following? (Tick all that apply)

Hair transplant PRP (Platelet-Rich Plasma) therapy Hair loss medications (e.g. finasteride, minoxidil) Laser/light therapy Topical or natural treatments Other (please provide details below)

Other details

MEDICAL HISTORY

Do you have any medical conditions? Are you currently taking any medications or supplements? Do you have any allergies (e.g. to medications, anaesthetics)? Do you smoke or vape? Do you drink alcohol regularly?

GOALS & EXPECTATIONS

What are your main goals for treatment? When would you ideally like to have the procedure? Have you had any previous hair transplant consultations?

ADDITIONAL INFORMATION

How did you hear about us? Comments and/or questions (optional)

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