Hair Transplants, Consultation, Hair Replacement, Hair Restoration, Hairloss Treatment, Melbourne, Australia
Dr Richard Shiell - Modern Hair Transplantation
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Online Consultation

Want to have a ‘Word with the Doctor’?


The online consultation form below presents a number of questions regarding the current extent of your hairloss and any history of hairloss in your family. Please take the time to fill out this online consultation form accurately, as the information you provide will greatly help Dr Shiell in preparing for your in-person consultation.

Rest assured that all medical information you provide is forwarded directly to Dr Shiell and will be treated in the strictest confidence.

If, at any stage, you have questions or wish to speak directly with someone at Dr Shiell's Modern Hair Transplantation Clinic, please call the clinic nearest to you:

Melbourne: (+61) 03 9867 6255

* required fields  
Contact Information  
*Name:
Age:
Address:
°Home phone:
°Business Phone:
°Mobile Phone:
*Email:
Occupation:
° - please provide at least one contact number

How would you like to be contacted?
Business Phone
Home Phone
Email
Personal history of hair loss
Age of onset:
*Extent of Hair Loss:
Which pictures best describe your hair loss? (Please tick at least one)
Type 1 Type 2 Type 3
Type 4 Type 5 Type 6
Type 1
Type 7 Type 8
Past or present treatment:
List any ongoing medical conditions:
List any medications required:
List past surgical operations:
Family history of baldness:
Please indicate if any of your following relatives have suffered mild, moderate or severe hair loss.
* Father:
* Paternal Grandfather:
* Mother:
* Maternal Grandfather:
* Brothers:
* Paternal Uncles:
* Maternal Uncles:
Other information you feel is pertinent or question /comments you may have
* required fields
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