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Name
*
Surname
*
Email
*
Phone
*
City
Age
*
Sex
*
Woman
Man
Types of baldness in women
*
Types of baldness in man
*
1
2
3
4
5
6
7
8
Were there problems with balding in the family? (father, mother, grandparents)
*
Yes
No
Describe problems with balding in the family
Are anti-hair loss products used?
*
Yes
No
Replace the medicines you use
How much hair falls out a day?
*
less than 20
20 - 50
more than 50
more than 100
Has the problem of hair loss been consulted?
*
Yes
No
Who was he consulted with?
Dermatologist
Family doctor
Trycholog
Hairdresser
Place of baldness
*
0% Complete
Back of the head
*
0% Complete
Left profile
*
0% Complete
Right profile
*
0% Complete
Information about the processing of personal data
*
I express my express and free consent to the processing of my personal data (name, surname, email address, telephone number, medical data and photos) by Individual Medical Practice Piotr Turkowski in order to present the offer of medical services. I declare that I am aware of the right to inspect my data and submit a request for correcting, supplementing, updating, temporarily or permanently suspending processing of data in question that I have questioned or completely removing my data from the collection to the extent provided for by the Regulation of the European Parliament and the Council of the EU 2016/679 of 27 April 2016 on the protection of individuals with regard to the processing of personal data and on the free movement of such data and the repeal of Directive 95/46 / EC
*
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