Book a Consultation | Cole Clinic

Javascript is required to submit this form.

First Name*

Last Name*

Phone

Email*

Age*

Address

Address Line 2

City

State/Province/Region

Postal/Zip

Country

Clinic Selector*

How did you hear about Cole Clinic?

e.g. A friend or family referral, an existing patient referral, Google search, YouTube, Hair Discussion website/forum (if so which one?)

Preferred Hair Growth Treatment Method*

Have you taken hair growth medication or products (e.g. Rogaine / Finasteride / Minoxidil)?*

Never Used

Currently using, but not consistently

Currently using as frequently as prescribed

When would you approximately like to have your procedure?

Describe your hair loss in detail

Previous Next

Upload Photos

Take photos in evenly lit and bright rooms. Do not use flash. Maximum file size should be 5MB per image, images should have less than 3200px x 3200px dimensions.
4 photos: Front, Back, Top, Side.

I agree*

By clicking "I agree" you are allowing Cole Clinic to provide an estimate about your hair loss treatment procedure based on the photos and information you provided. Your submitted pictures will be private and secure and will not be used without your permission.
Please note a final consultation will be needed and all costs are estimates and may be subject to change.

Required Fields*

Javascript is required to submit this form.

Our Locations

Our Services

Contact Info

Follow Us Online