Pre-Consultation Form

Please complete the pre-consultation form prior to attending your consultation appointment.

Note: If you want a report after the consultation, it will incur £120. This will take about 2 weeks to be made.

Trinity Trichology Clinic

33, Down Way, Northolt, UB5 6PG

Phone

07956 293 093

Email

belinda.akobel@gmail.com

First Name

Last Name

Email

WhatsApp/Phone Number

Date of Birth required

Address

Occupation

How long have you worked in this position?

Sex

Male

Female

Prefer not to say

Other (specify)

Medication List

List Previous Medication

Other (specify)

How long has it this condition been?

Other (specify)

Have you seen any healthcare profession before? For example, dermatologists, Trichologist, or doctors

Yes

No

Do you already have a diagnosis?

Yes

No

If yes, name of diagnosis

Have you had any previous Hairloss Treatments (names of treatment and year )

Dr/GP Name

Address

Medical History (food, medication, known deficiencies e.g. iron, vitamin D, alergies, intolerances, thyroid) Please give details.

When was the last time you had a blood test?

Have you given birth within the last 6 months?

Yes

No

List of Medications - Including contravceptives

Are you currently receiving any medical attention? Give details if applicable.

Accidents

Have you had any operations in the last 3 years? Give details if applicable.

Please give a brief description of when and how your hair started thinning/shedding/breaking.

Upload a picture of the back of your hair

Upload File

Upload supported file (Max 15MB)

Upload a picture of the front of your hair

Upload File

Upload supported file (Max 15MB)

Upload a picture of the side of your hair

Upload File

Upload supported file (Max 15MB)

Upload a picture of the other side of your hair

Upload File

Upload supported file (Max 15MB)

I accept terms & conditions

Thank you for completing the pre-consultation form. Your answers will be reviewed prior to your appointment

Facebook

Twitter

Instagram