The Clinic is going to be closed for our annual holiday leave from July 19th till August 15th.

Application form


If you are going to be treated at our clinic please fill in this application form.
Primary consideration of your case is free.

 

The fields with asterisk (*) are obligatory

* Your First Name:
* Your Last Name:
Street Address / PO box: Street Address - pt II:
* City: State/Province: Zip/Post Code:
* Country:
* E-mail: * Confirm Email:
Fax:
Daytime Phone: Evening Phone:
How did you Find us (if by the Internet please indicate search engine):
* Your Age:
* Gender:
Male:         Female:
The age when the first patch of hair loss occured:
The age when significant part of your scalp hair was affected:
* Total duration of the disease:
less than one year        less than 5 years        more than 5 years

I took the following medicines for Alopecia treatment according to doctor's prescription:

Prednizone or/and other steroid hormones as system (oral) treatment: Yes        No

If Yes, please write down the names:

Cytostatics: Yes        No

I was treated by:

Injections of corticosteroids directly onto and around the bald area(s) Yes        No
PUVA-therapy Yes        No
Have you got topical sensitizing therapy? Yes        No

If you do not know how to classify medicines and treatments just write them down:

I suntanned much with uncovered head for long periods of time: Yes        No
I wear a wig all the time: Yes        No
My finger and thumb nails have changed: Yes        No
My pubis and armpits are hairless: Yes        No
Question for Alopecia universalis sufferers only
Have your finger and thumb nails changed: 		Yes        No

If yes, when in the course of the disease did your finger and thumb nails change (indicate details, if possible):

Have you ever noticed short hair (up to 6-8mm long) with thicker outer ends in the affected areas of the scalp (like the shape of exclamation mark)? Yes        No

If yes, in what period of the disorder:

The first bare patch appeared at the edge (hair line) of the scalp: Yes        No
The first bare patch appeared at the back of the head Yes        No

Please fill in any other questions, or comments:

Please reply by: E-mail      Fax      Post

 

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