Surabaya Hairtrans Clinic
Ask The Doctor

Online Consultation Form

Surabaya Hairtrans Clinic provides Online Consultation service to allow patients or those who need information gather the appropriate knowledge right from the source. Dr. Bambang will personally answer each question.

This Online Consultation media is one of the prime service program given for free by Surabaya Hairtrans Clinic.

To start consulting, please fill in the form below.

Age *
Hair Loss *
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Ancestral :
Hair Color * :
Skin Color :
Hair Density :
Hair Texture :

Please provide your personal data, to keep us in touch:

Name * :
Gender * :
Email * :
Country :
Address :
Phone :

Write your question in the column below:

Message * :
     
     
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