Selenium Retro Blok Ofis: 202-203
Ataköy - Bakırköy/İstanbul
Please send us your pictures in this form in order to get your doctor’s report.
Upload Picture Front:
Upload Picture Side:
Upload Picture Up:
Upload Picture Back:
1-Have you gone through any previous surgical or cosmetic operations?
2-Do you take any medication?
3-Do you suffer from any permanent diseases (diabetes, blood pressure, cholesterol, etc.)?
4-Do you have any allergies?
5-Do you smoke or drink?
6-Have you determined the date of your arrival to Istanbul? If so when is it?
Since when you're suffering from hair loss?
1 - 3 years3 - 5 years5 - 10 yearsMore than 10 years
Full name: *
Date of Birth: *
City State / Province / Region
© 2019 Clin Medica. All Rights Reserved