Online Diagnosis Form
   

By completing the Online Diagnosis Form, you enable us to draw reliable and accurate conclusions. Through a detailed assessment of the information and photos you provide to BERGMANN KORD, our doctors can ascertain:

  • Whether you have a donor area that is suitable for a hair transplant procedure

  • The hair transplant method best suited to you

  • The number of follicular units needed to achieve the desired result.

The number of follicular units required is the main factor in determining the cost of your personal treatment. Our calculations take into account the type and extent of thinning, the desired degree of thickness and your personal goals.

You will receive a prompt answer and will be informed in detail regarding the cost of your personal treatment and everything else you need to know in order to move ahead confidently to a hair transplant.

Attachment of photos will be a very helpful factor in our evaluation.

Your photos must include the thinning as well as the donor area.

In the field YOUR MESSAGE/COMMENTS, you may describe your hair thinning history, ask any questions you may have or add any information that you think might contribute to our evaluation.

Thank you for your interest in BERGMANN KORD.

NAME:
SURNAME:
CITY:
COUNTRY:
ADDRESS 1:
POSTCODE 1:
ADDRESS 2:
POSTCODE 2:
* SEX:
* AGE:
PROFESSION:
* E-MAIL:
TELEPHONE:
MOBILE PHONE:
CONTACT TELEPHONE / DAY:
CONTACT TELEPHONE / NIGHT:
* HAIR LOSS CLASSIFICATION FOR MEN:
Type I Type II Type III Type IV
Type V Type VI Type VII Type VIII
Type IX Type X Type XI Type XII
* HAIR LOSS CLASSIFICATION FOR WOMEN :
Type I Type II Type III
*IS THERE A FAMILY HISTORY OF HAIR LOSS?
Yes No
*AT WHAT AGE DID YOUR HAIR LOSS BEGIN?
Before 20 21-30 31-40 41-50 After 50
*HOW WOULD YOU DESCRIBE THE HAIR IN YOUR DONOR AREA?
DENSITY EXTENT
Scanty Small
Medium Medium
Dense Large
*HAIR TYPE AND TEXTURE:
Thin and straight Thin and a little bit curly Normal and a little bit curly Normal and curly Very thick and curly
*HAIR COLOR:
BLACK/ DARK BROWN HAIR BROWN GREY LIGHT BROWN / RED / BLOND
PLEASE SELECT THE TYPE AND PERCENTAGE OF THE BALD AREA THAT YOU WISH TO COVER:
FRONT AREA:
UPPER AREA:
CROWN:
I ONLY WISH TO PRESERVE THE EXISTING HAIR
HAVE YOU PREVIOUSLY CONSULTED A DOCTOR ABOUT HAIR LOSS?
IF YES, PLEASE INFORM US, REGARDING THE DIAGNOSIS AND TYPE OF TREATMENT:
ARE YOU UNDERGOING ANY CURRENT MEDICAL TREATMENT FOR HAIR LOSS?
IF YES, PLEASE ADVISE US OF THE TYPE OF THE TREATMENT:
HAVE YOU PREVIOUSLY UNDERGONE A HAIR TRANSPLANT PROCEDURE?
IF YES, PLEASE ADVISE US OF THE NUMBER OF SESSIONS, THE METHOD EMPLOYED AND THE NUMBER OF GRAFTS. HOW LONG AGO DID YOU HAVE THE LAST SESSION?:
PLEASE ATTACH YOUR PHOTOS:
PHOTO 1:  
PHOTO 2:  
PHOTO 3:  
PHOTO 4:  
IF YOU WISH TO SEND YOUR PHOTOS BY POST, PLEASE SEND THEM TO:
BERGMANN KORD
348, KIFISSIAS AVE., CHALANDRI
15233, ATHENS
GREECE
YOUR MESSAGE / COMMENTS:
HOW DID YOU LEARN ABOUT BERGMANN KORD?
   
OUR CLINIC GUARANTEES THE CONFIDENTIALITY OF YOUR PERSONAL INFORMATION
*Required Fields