Online Photo Consultation Cosmetique Lahore Pakistan


Online Photo Conslutation


If you would like to have a photo consultation with our doctors please complete the form, and upload photo or email us.

 

Tell us how to get in touch with you:

Name

E-mail

E-mail (Again)

Address

Telephone

Cell Phone

Age At Which Your Hair Loss Began:    

Date Of Birth:

 ( DD / MM / YYYY )
 

Current Age:

Years

Gender:

Male    Female


Relevant Medical History Or One That Might Affect Hair Transplant Surgery ( Such As Diabetes ):

Previous Hair Transplant Procedures Or Other Types Of Their Restoration Surgery. Please Indicate Type Of Procedures And Date (If Known).

How Did You Hear About Us:


Any Question/Other Details:


Attach Photos (Front View, Side Views, Back View)

 ( All Photos Must Be in .jpg or gif Format )

Attach File:
Attach File:
Attach File:
Attach File:
Valid Attachment Types: .zip, .rar, .txt, .doc, .jpg, .png, .gif, .odt, .xml
Max size per file: 1024 kb.
Max combined file size: 2048 kb.

 

 
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Dr. Azim J. Khan
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