Contact

For us, it’s all about your beauty & confidence. To start the process, please call us on the number below.

Alternatively, you are welcome to either complete our online form. If you have a specific query, simply fill in the boxes on this page, send us a message and we’ll aim to get in touch with you the same day.

Contact

77a Botanic Avenue BT15 1JL
Northern Ireland, Uk.

+44 7359 112051

+44 28 9096 4731

tesshairandscalpclinic@gmail.com

info@hairlosstreatment-belfast.com

Pre-Consultation Form

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

First Name

Last Name

E-mail

Date of Birth

Address

Phone

Sex

Male

Oui

Prefer not to say

Have you given birth within the last 6 months?

Yes

Dr/GP Name

Occupation

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

Have you had a blood test in the last 6 months? Please upload the results.

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List of Medications - Including contravceptives

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

Accidents

Illnesses

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

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Upload a picture of the front of your hair

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Upload a picture of the side of your hair

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Upload a picture of the other side of your hair

Upload File

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I declare that the information I have provided is accurate and complete

Thank you for what you sent !