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護髮
療程經過
療程組合
美容
骨膠原蛋白激活劑
皮下填充劑
抗皺注射
雙眼皮埋線
激活骨膠原蛋白埋線
瘦顎V面
肌膚補濕劑
去雙下巴
面部及身體塑形
護膚
皮膚問題
皮膚治療
雙脈衝 Q-switched Nd:YAG
分段式換膚
Liftera
Scarlet SRF
Ultherapy
Alex Trivantage
DermaStamp
化學換膚
美體
Emsculpt Neo
減汗療程
私密緊緻治療
纖瘦小腿
靜脈注射治療
淨亮肌膚加強版
醒神舒壓
免疫加強版
NAD+加強版
淨肝排毒加強版
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Quiz
Adrian Ong
2023-03-20T14:05:53+08:00
請填寫我們的髮型問卷。這些資訊將會提供給我們的醫生,如果您選擇預約諮詢,醫生將會審查您的資訊。在您完成問卷後,我們的工作人員會與您聯繫,安排預約。
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What is your gender?
*
Male
Female
When were you born?
*
E.g. 21/11/1980
Day
Month
Year
When did you start losing hair?
*
In the last 6 months
In the last 12 months
1-5 years ago
5+ years ago
Which one of these closest represents your current hair?
*
One
Two
Three
Four
None of these
Which one of these closest represents your current hair?
*
One
Two
Three
None of these
What was the rate of your hair loss?
Rapid
Gradual
Fell out in patches
Other
Other - please describe
Does hair loss run in the family?
Tick all that applies
Father
Mother
Siblings
Grandparents
Other
Do you have any known illnesses/conditions or have had any recently surgery?
If none, leave blank.
Have you or are you using medication or supplements for hair loss?
*
No
How effective was the treatment?
Very effective
Somewhat effective
Not effective at all
Did you experience any side effects?
No
Yes
Are you currently on any other medications or supplements? (not for hair loss)
*
No
Do you have any specific drug allergies?
*
No
Does any of the following apply to you?
*
Tick all that applies
Low or high blood pressure
Pregnant or breastfeeding
Planning to start a family
Dandruff
Scalp conditions (e.g. fungal infection)
Recent high levels of stress
None of the above
Have you ever experienced any of the following?
*
Tick all that applies
Symptoms of heart failure
Kidney (renal) failure
Liver disease
Chest pain
None of the above
Given the choice of hair loss treatment, I would prefer:
Topical Solutions
Oral Tablets
Scalp Injections
Whatever I need for the best results
How would you budget for hair loss treatment?
Keep costs as low as possible
I want the best value
I want the finest treatment available
Comments (if any)
If convenient, please upload a photo of your hair for our doctor to see.
Please ensure the photo is clear.
Drop files here or
Select files
Accepted file types: jpg, png, Max. file size: 512 MB.
Full Name
*
First Name
Last Name
Mobile Number
*
Email
*
example@example.com
Address
Street Address
Address Line 2
City
How did you hear about us?
Google
Facebook / Instagram
Advertisement
Walked or drove by
Referred by someone
Other
How would you like to be contacted by our staff?
Phone call
SMS
Whatsapp
Email
I will call myself to make a booking
Do you CONFIRM that the information you have given is TRUE and ACCURATE, that this medication is solely for yourself, and that if prescribed a medication, you will review the information supplied regarding the medication and side effects?
*
YES
NO
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Phone
This field is for validation purposes and should be left unchanged.
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