Booking Form

Woman

Man

None

Light

Light-Medium

Medium

Extensive

Completely

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Years

Less than 1 year

More than 10 years

No

Yes

Use the calendar to choose a date (only valid dates are accepted).

Select all that apply.

Minoxidil (topical)

Finasteride / dutasteride or similar (prescription)

PRP, stem cell, or similar injections

Low-level laser therapy / devices

Hair fibers / concealers

Nothing yet

Other

As soon as possible

Within 3 months

In 1 year

I haven't planned it yet.

Medication, allergies, or medical conditions ?

Instagram

Facebook

Google / Search Engine

Friend or family

Another clinic or doctor

Other

* Indicates required question

Full Name *

E-Mail Address *

Your Telephone Number *

Example: +1 555 123 4567 (WhatsApp reachable preferred)

City and Country

Do you speak English? *

Yes

No

Other

Willing to travel to Istanbul, Turkey? *

Yes

No

Not Sure

Anything else you want us to know? Optional — leave blank if you have nothing to add.

I consent to UniquEra processing my information for pre-assessment and contact.

I confirm the information provided is accurate to the best of my knowledge.

I agree to be contacted via WhatsApp/Phone/Email about my case.

Hair Transplantation Planning Consultation

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Choose your hair loss in the frontal area.

Choose your hair loss in the crown area.

Thank you