Email Consultation

Although a one to one consultation in person with Dr. Kiely at his Dublin or Cork offices is highly recommended we understand that some patients may have difficulty in travelling. If, on the basis of the email consultation, you decide to proceed further a consultation, in person with Dr. Kiely will take place before any surgery is carried out.

Please complete all the sections below. All information is treated in the strictest confidence.

First Name
Surname
Email
Address


Contact Telephone Number (Incl Local Area code)
Age
Please choose one of the illustrations below which best represents your pattern of hair loss:

Have you previously had any kind of hair restoration done before?
Yes
No
If 'Yes' please specify
Are you suffering from any medical illness or taking any medication?
Yes
No
If 'Yes' please specify

As previously stated ALL communication with Dr. Kiely is strictly confidential.

Please include any further information that you consider may be relevant: Other Info
Thank you for providing this information. Dr Kiely will contact you shortly.

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