ONLINE CONSULTATION Online Consultation Patient Intake Form (#71)First Name Last Name City Country Email Phone number WhatsApp Number Gender - Select -MaleFemaleOthersAge Please provide pictures of your hair loss and donor area for an accurate assessment. Please upload clear and full picture profiles of: 1.Front2.Top3.Sides4.BackExpose all loss and without any concealer.Upload Consultation Photos Choose Images Other Files (Optional) Choose File Family Hair Loss? - Select -NoneFatherMotherBothPlease specify family members and extent of loss Are you taking any hair loss medications? - Select -NonePropeciaMinoxidilPropecia & MinoxidilTopical FinasterideLasercombVitaminsWhat are your hair transplant goals and what would you like to achieve? Dr Bisanga needs the contact information you provide to us to contact you about our products and services. You may unsubscribe from these communications at any time. For information on how to unsubscribe, as well as our privacy practices and commitment to protecting your privacy, please review our Privacy Policy.Submit