Online Diagnosis

2 ➜ Last Name *

Please enter your last name

3 ➜ Email *

Please provide your email address

4 ➜ Phone Number *

Please provide your phone number

5 ➜ Age *

Please type your current age

6 ➜ How did you hear about Bergmann Kord; *

7 ➜ Select your preferred clinic location *

8 ➜ Preferred Method*

Open to the method rcommended by the doctorI prefer FUEI prefer FUTI’m interested in a combination

9 ➜ Have you had hair transplant surgery before? *

A. YESB. NO

10 ➜ Have you used Finasteride? *

A. Never UsedB. Currently usingC. Stopped using

11 ➜ Have you used Minoxidil? *

A. Never UsedB. Currently usingC. Stopped using

12 ➜ Approximate date you would like to have your procedure*

Within the next 1–4 weeksIn 1–3 monthsIn 3–6 monthsIn more than 6 months

13 ➜ Tell us your hair loss story (optional)

Note:

14 ➜ Describe your restoration goals (optional)

15 ➜ FRONT photo *

Instructions

1. Ensure that the room is evenly and adequately enlightened.

2. Do not use flash.

IMPORTANT NOTES
1) Maximum allowed file size: 5MB
2) For security reasons, only the following seven (7) file types are accepted: gif, png, jpg, jpeg, pdf, mp3, mp4

16 ➜ BACK photo *

IMPORTANT NOTES
1) Maximum allowed file size: 5MB
2) For security reasons, only the following seven (7) file types are accepted: gif, png, jpg, jpeg, pdf, mp3, mp4

17 ➜ SIDE photo *

IMPORTANT NOTES
1) Maximum allowed file size: 5MB
2) For security reasons, only the following seven (7) file types are accepted: gif, png, jpg, jpeg, pdf, mp3, mp4

18 ➜ Crown photo *

IMPORTANT NOTES
1) Maximum allowed file size: 5MB
2) For security reasons, only the following seven (7) file types are accepted: gif, png, jpg, jpeg, pdf, mp3, mp4

20 ➜ Submit Photos *

By clicking on "I accept", you allow Bergmann Kord to give you an accurate assessment of your case based on the photos you submit. Your photos will remain private, will be kept secure and will not be used without your permission.
A. AcceptB. i don't accept