Home Use, Mail-Order Hair Loss Service

Britain's leading
hair loss clinic and
pharmacy

Contact us by sending an instant message to the centre if you have any questions or would like to arrange a free consultation for hairloss.

Call our help-line on
020 7730 6666

ABOUT THE CENTRE

VISITING BELGRAVIA

CLINIC WARNING

ON-LINE DIAGNOSTIC FORM

PATIENT PHOTO SCANS

Home Page Male Hair Loss Female Hair Loss Scalp Problems
Book A Tricho-Check Before and During Treatment Photo-Scans

ONLINE CONSULTATION

Home

Online Hair Loss Diagnostic form for Mail-Order

Belgravia’s online hair loss diagnosis form is designed specifically for those who are unable to visit our London centre for a free consultation. The form takes less than 5 minutes to complete and provides Belgravia’s trichologists with all of the information required to diagnose your hair loss condition and recommend a superior Belgravia treatment programme for hair loss, which can be delivered to your home address without the need for you to visit our Central-London clinic.

Our home-use treatment courses can include all of the same treatments as the treatment programmes used by those who live in London and visit the centre. Although you will not be able to take advantage of our photo-monitoring service, we advise anybody using a home-use treatment course to take your own photos in order to monitor your treatment response. Should you decide to use a Belgravia Centre home-use treatment course, you will be appointed a dedicated trichologist and treatment advisor who you will be able to speak to at any time during working hours should you have any questions or queries regarding your treatment.

Once you press the ‘submit’ button at the bottom of the form it will be sent directly to a Belgravia trichologist who will examine the form, diagnose your hair loss condition and recommend the optimum course of hair loss treatment to suit your individual condition and stage of hair loss. You will then be contacted by a Belgravia treatment advisor who will discuss your diagnosis and treatment recommendations, answer any questions you may have, and inform you of costs, within 48 hours.

Please try not to leave any questions unanswered. If any questions are left unanswered we will assume that this question does not apply for you.

If you would prefer to visit our London centre to see a trichologist in person please contact us by MESSAGING THE CENTRE or calling 020 7730 6666. Please scroll down for the online diagnostic form.

If you require more information on our hair loss services once you have completed the form here are some useful pages: Male Hair Loss | Female Hair Loss | Before and During Treatment Hair Loss Photos

PERSONAL DETAILS

Please tell us about yourself :

The entries with a * by the box must be filled in.

Title :

Mr Mrs Miss Ms *

First Names :

Surname :

Street and Number :

Town / City :

County :

Postcode :

Best time & day for us to call you
(between 10am-8pm)

Country :

Telephone :

Home :

Work :

Mobile :

Occupation :

Fax :

E - Mail :

Confirm E - mail :

Date of Birth :

Year	Month	Day

Sex :

Female Male


How did you hear about the Belgravia Centre?	*


Is the problem you are experiencing :	Hair Loss ?	Scalp Problem ?

HAIR LOSS

Are you experiencing hair loss?

On the top of your head	On the top and sides of your head (all over scalp)	Is the hair loss sudden with smooth, round bald patches appearing in less than 3 months


How long have you suffered with hair loss or thinning?	Less than 1 year, please state the exact duration.

Approximately how much hair are you left with on the head?
Under 25%	25-50%	50-75%	Over 75%
Approximately how much hair are you left with in the affected areas?
Under 25%	25-50%	50-75%	Over 75%

Have you experienced total hair loss on your head ?
Yes	No
Have you experienced total hair loss on your face ?
Yes	No
Have you experienced total hair loss on your body ?
Yes	No

Is there a history of hair loss in your family? If so, which family member(s)?
Father
Mother
Grandparents
Uncle
Brother or Sister
Is your hair type :
Caucasian (European)
African (Afro-Caribbean)
Mongoloid (Asian)

Other

YOUR LIFESTYLE

Is your general health and fitness :

Are you under constant pressure or stress?
Yes	No
Do you work in an environment that exposes you to chemicals on a daily basis?
Yes	No

HAIRSTYLE

Do you use extensions or a weave-on ?
Yes	No
Do you plait or braid your hair ?
Yes	No

HARE CARE ROUTINE

How often do you shampoo?
Do you use chemicals on your hair? e.g. bleach, perm solutions, hair colourings, relaxers or any other.

Yes
	Which ones ?
	How often ?
No

YOUR SCALP

Is your scalp :
Flaky?	Itchy?	Dry?
Oily?	Normal oiliness?	Have spots or acne?
Prone to dandruff

Does your scalp weep or is there a crust build up ?
Yes	No

Please describe any other symptoms.

MEDICAL PROFILE

What is your current blood pressure level? (Please have this measured by a reliable person i.e. your G.P.)

Have you had a blood test in the last 6 months?
Yes	No

Do you have any of the following conditions?
Anaemia	Thyroid Problems	Liver Problems
Hormone Imbalance	Diabetes	Migraine
Prostate Problems	Renal Failure	Crohn's Disease
Depression	Endometriosis
Polycystic Ovarian Syndrome
Hypertension (High blood pressure)
Hypotension (Low blood pressure)

Other conditions, or expand on previous answers ?

Are you currently having treatment by chemotherapy and/or radiation therapy?
Yes	No
Do you take any prescription medicines?
Yes	No

Do you have an iron deficiency, or any other form of dietary deficiency?

Yes

Unsure

Do you have an allergy to lactose?

Yes

Do you have any other allergies?

Have you used any medication or treatment for your hair loss or scalp conditions in the past?

Yes

If you have used any of the treatments listed below for hair loss or a scalp problem please let us know:

Nourkrin

Procerin

Provillus

Revivogen

Regaine

Propecia

Other Treatment 1

Other Treatment 2

Other Treatment 3

Have you received treatment or advice from :
Trichologist	Hair dresser	Dermatologist

G.P.	Other
If yes, what advice ?

What form of contraception do you use, if any?
The Pill	Barrier Contraceptives (ie condoms)	Other

Have you recently given birth?
Yes	No
Do you breast feed?
Yes	No
Are you, or is your partner currently pregnant ?
Yes	No
Are you thinking of trying for a child in the next 12 months?
Yes	No
Are you a professional sports person?
Yes	No
Have you had a raised temperature/fever due to illness in the last 3-6 months?
Yes	No

DIETARY HABITS

What type of diet do you have?
Mixed Diet
Lacto Vegetarian (milk/cheese and vegetarian diet)
Piscatarian Diet (Fish and Vegetarian Diet)
Vegan (Purely Vegetarian)
Other

Do you take any mineral or vitamin supplements?
Yes	No	If yes :
Has your weight changed dramatically in the last 12 months?

Weight Loss	Weight Gain	No Dramatic Weight Change

EXTRA COMMENTS

If you have any extra comments about your hair loss or scalp problem please inform us in the space provided.


Please click here to read our Information and Privacy notice before continuing.
By clicking submit, I hereby state that all my answers to the above questions are true as to the best of my knowledge. Please read the above disclaimer before submitting the form.


To book a tricho-check call our reception on 020 7730 6666 or send an instant message directly to the centre. We are open 7 days a week with 4 late nights.

The Belgravia Centre - Tel 020 7730 6666
© Belgravia Centre 2009 - www.belgraviacentre.com - All Rights Approved - Male & Female Hair Loss Treatments
The Belgravia Centre, 52 Grosvenor Gardens, London, SW1W 0AU, England
RSS Feed \| Contact Us \| Site Map \| Disclaimer