Your personal information

First Names *

Surname *

Sex *

Male Female

Your address

Country of residence *

First address line *

Second address line

Third address line

Town *

County

Postcode *

Why don't you come in for a clinical consultation?

If you are from in or around London we always recommend a consultation at one of our clinics where possible

Book Consultation

Continue Below with Online Consultation

Your contact details

What is your email address? *

Confirm your email address *

Privacy

If other:

Which image(s) of hair loss are close to your own experience?

Tick all that apply.

On the top of your head only

On the top and sides of your head (all over scalp)

At the front (receding hairline)

At the back/vertex area

Is the hair loss sudden with smooth, round bald patches appearing in less than 3 months

Do you experience any of the following scalp symptoms?

Tick all that apply.

Flaky?

Itchy?

Dry?

Oily?

Normal?

Have spots or acne?

Prone to dandruff

Other

Have you been diagnosed with any of the following scalp conditions?

Tick all that apply.

Eczema or seborrhoeic dermatitis

Psoriasis

Dandruff

Acne

Folliculitis

Other

Please list any medications that you take

This should also include any hormonal treatments (e.g. HRT), forms of contraception (e.g. pills, IUDs, implants, injections, patches) or fertility treatments (e.g. IVF).

Please list all medications below:

Please list any supplements that you take

This should also include any hormonal treatments (e.g. HRT), forms of contraception (e.g. pills, IUDs, implants, injections, patches) or fertility treatments (e.g. IVF).

Please list all supplements below:

Are you currently:

Please select:

Trying for a child in the next 12 months?

Is your partner currently pregnant?

Is your partner currently breastfeeding?

Are you currently:

Please select:

Trying for a child in the next 12 months?

Pregnant?

Breastfeeding?

Any further comments

If you have further comments, please add them below:

Please tick to confirm all the information you have provided is correct and accurate, and that all information requested has been provided. *

Please tick to confirm that should you receive medication from The Belgravia Centre, you will read the Patient Information Leaflet provided with the medication before using it. *

Photo upload

Please upload your photos here. To upload - browse for your photo, add the date and then press “Upload photo”. Once you have added a photo, you are able to add further photos, but they must be uploaded one at a time.

If you do not wish to add photos, please press “Next step” to continue to the final page of the form.

Photo date

Please click on the image below for a larger version examples of well-taken photos.

Would you like to speak with one of our hair loss specialists by phone or video?

To arrange a video-consultation or phone-consultation with a Hair Loss Specialist, please advise us of a suitable time and we will contact you to confirm your appointment.

Day of the week

Time of day

You’re all done

Thank you for completing our online consultation. You will be contacted shortly with details of your diagnosis and treatment recommendations.

Online Consultation

About you

Your hair loss

Your scalp

Your health

Your medications

Family

Anything else we should know?

Photos

Booking your e-consultation

Online Consultation

Your personal information

Your address

Your contact details

Privacy

Which image(s) of hair loss are close to your own experience?

Do you experience any of the following scalp symptoms?

Have you been diagnosed with any of the following scalp conditions?

Do you experience any of the following?

Please list any medications that you take

Please list any supplements that you take

Are you currently:

Are you currently:

Any further comments

Photo upload

Would you like to speak with one of our hair loss specialists by phone or video?

You’re all done