Specially Trained in Hair Restoration Procedures.

PATIENT QUESTIONNAIRE

Name:
 
Age: Sex : M/F
Address:
 
Blood Group: Date:
Phone No.:
 
E-Mail Id: D.O.B:
Are you on WhatsApp : Yes/No
 
Max Clinique suggested by: Friends / Doctor / Website / Print Advt. / TV Advt. / SMS or WhatsApp Advt.
 
History of any Medical Illness (Diabetes, Hypertension, Asthma, Seizure):
 
History of any medication for Hair Loss or any other ailment:
 
Allergy to any drug:
 
Previous history of Hair Transplant/Any other Procedure on Hair:
 
Have you had any surgery/Tooth Extraction before:
 
Have you had any local anaesthesia before? :
 
Do you Smoke: Y/N
 
Do you take alcohol: Y/N  
History of Hair loss in family members:
 
Any music preference (You may bring VCD of your choice to watch during surgery) :
 
Food preference:
 
Your preferred method of Payment: Cash / Card / Cheque / Draft / Online
 
We need an advance payment of Rs.10, 000/- (Ten thousand only) to book a surgery. Balance full payment to be paid before the surgery either by cash/card only. If you wish to make online transfer, please ask for our account number. If you need any hotel accommodation or pick up from airport, it can be arranged if informed well in advance. Any change in the date once booked can be done if informed in advance (14 days). Last minute request for the change in date may result in forfeiting the advance. Please collect your pre operative and post operative instructions sheet well in advance.
 
Investigations mandatory prior to the surgery : CBC, BT/CT, Blood Sugar, KFT, LFT, Lipid Profile, ECG, CxRPA, HIV I & II, HbSAg, PT/APTT, Anti HCV
 
Assessment by the Doctor:                     Pulse:                     BP:                     RR:                    Chest:                     CVS:
 
Anaemia / Jaundice:
 
  Any other systemic illness:
 
Degree of Hair loss:
 
 
Technique planned:
   
Signature of Doctor: