On-Line Photo Consultation | Sure Hair Transplants

Please Note When taking photos please ensure you take:
1 of the front of your face (including your hairline),
1 of each side,
1 of the top and also
1 of the back of your head.
(Please ensure each photo being sent is less than 350 Kilobytes and in .JPG .JPEG, .GIF and .PNG)

Upload Photo of the front of your face (including your hairline):
Upload Photo of each side:
Upload Photo of the top of your head:
Upload Photo of the back of your head:

First Name :

Last Name :

Email Address :

Phone Number :

Mailing Address :

Apartment or P.O. Box :

City :

State/Province :

Postal Code :

Which of our office locations would you prefer to visit for your consultation/Treatment? :

Current Age :

Gender :

Hair Loss Info :

What areas of thinning concern you?” Please be specific :

Have you had a previous hair transplant or other restoration surgery? :

If yes, please indicate date and the type of procedure. Give as much info as possible. :

Please list any past or current medical conditions that you feel might interfere
with a hair transplant procedure (i.e. Diabetes, Keloid and Heart) :

Are you taking any current hair loss treatment or medication? :

Please verify that this is a legitimate inquiry :