Hair Implant Questionnaire


      Date of Birth :
Sex:          Age:
            CM     KG

● Description of the degree of hair loss basis self-examination:

   

● 為In order to avoid adverse effects in the procedure, please check all applicable conditions listed below:


  
that was  

● Please check all applicable conditions listed below:

          
        Abnormal Coagulatory Function
    

● Medicine(s) taken recently; please check each appropriate item:

  Aminoglycoside-type Antibiotics    Bokey-brand Pain-killers