Online Consultation Form

The online consultation form below presents a number of questions regarding the current extent of your hairloss and any history of hairloss in your family. Please take the time to fill out this online consultation form accurately, as the information you provide will greatly help Dr Knudsen in preparing for your in-person consultation.

Rest assured that all medical information you provide is forwarded directly to Dr Knudsen and will be treated in the strictest confidence.

If, at any stage, you have questions or wish to speak directly with someone at Dr Knudsen's Hair Transplantation Clinic,
please call the clinic nearest to you:
(03) 9867 6255 for Melbourne or
1800 685 399 Australia wide.

Contact Information

Family History

Please indicate if any of your following relatives have suffered mild, moderate or severe hair loss.

How would you like to be contacted?

Personal History of Hair Loss?

Extent of Hair Loss

Which pictures best describe your hair loss?

Medical History

Other Information...

* Required fields