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For general information please complete the form below and it will be directed to the appropriate individual within our office.</p><p style="text-align: left" class="vc_custom_heading" >We want you to be the happiest, healthiest and most beautiful person you can be, both inside and out. 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data-popmake="{"id":21967,"slug":"appointment-form-pop-up","theme_id":21961,"cookies":[],"triggers":[{"type":"click_open","settings":{"cookie_name":"","extra_selectors":""}}],"mobile_disabled":null,"tablet_disabled":null,"meta":{"display":{"stackable":false,"overlay_disabled":false,"scrollable_content":false,"disable_reposition":false,"size":"small","responsive_min_width":"0%","responsive_min_width_unit":false,"responsive_max_width":"100%","responsive_max_width_unit":false,"custom_width":"640px","custom_width_unit":false,"custom_height":"380px","custom_height_unit":false,"custom_height_auto":false,"location":"center","position_from_trigger":false,"position_top":"100","position_left":"0","position_bottom":"0","position_right":"0","position_fixed":false,"animation_type":"fade","animation_speed":"350","animation_origin":"center top","overlay_zindex":false,"zindex":"1999999999"},"close":{"text":"","button_delay":"0","overlay_click":false,"esc_press":false,"f4_press":false},"click_open":[]}}" role="dialog" aria-hidden="true" > <div id="popmake-21967" class="pum-container popmake theme-21961 pum-responsive pum-responsive-small responsive size-small"> <div class="pum-content popmake-content"> <div class='gf_browser_chrome gform_wrapper _wrapper gf_stylespro_wrapper sp_glass_wrapper' id='gform_wrapper_6' ><div id='gf_6' class='gform_anchor' tabindex='-1'></div><form method='post' enctype='multipart/form-data' target='gform_ajax_frame_6' id='gform_6' class=' gf_stylespro sp_glass' action='/appointment/#gf_6'> <input type='hidden' class='gforms-pum' value='{"closepopup":false,"closedelay":0,"openpopup":false,"openpopup_id":21967}' /> <div class='gform_heading'> <h3 class='gform_title'>Consultation Booking</h3> <span class='gform_description'></span> </div> <div class='gform_body'><ul id='gform_fields_6' class='gform_fields top_label form_sublabel_below description_below'><li id='field_6_7' class='gfield field_sublabel_below field_description_above gfield_visibility_visible o_medium' ><label class='gfield_label' for='input_6_7' >Country</label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_6_7' class='large full gfield_select' aria-invalid="false"><option value='' selected='selected' class='gf_placeholder'>Choose an option</option><option value='United Kingdom' selected='selected'>United Kingdom</option><option value='United State' >United State</option><option value='Brazil' >Brazil</option><option value='Czech republic' >Czech republic</option><option value='France' >France</option><option value='Spain' >Spain</option><option value='Sweden' >Sweden</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Nigeria' >Nigeria</option><option value='Ireland' >Ireland</option><option value='Dubai' >Dubai</option></select></div></li><li id='field_6_11' class='gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible o_medium' ><label class='gfield_label' for='input_6_11' >Preferred Clinic<span class='gfield_required'>*</span></label><div class='ginput_container ginput_container_select'><select name='input_11' id='input_6_11' class='large full gfield_select' aria-required="true" aria-invalid="false"><option value='' selected='selected' class='gf_placeholder'>Choose an option</option><option value='London, UK' >London, UK</option><option value='Sheffield, UK' >Sheffield, UK</option><option value='Southampton, UK' >Southampton, UK</option><option value='Belfast, UK' >Belfast, UK</option><option value='Birmingham, UK' >Birmingham, UK</option><option value='Bristol, UK' >Bristol, UK</option><option value='Cambridge, UK' >Cambridge, UK</option><option value='Cardiff, UK' >Cardiff, UK</option><option value='Edinburgh, UK' >Edinburgh, UK</option><option value='Glasgow, UK' >Glasgow, UK</option><option value='Leeds, UK' >Leeds, UK</option><option value='Liverpool, UK' >Liverpool, UK</option><option value='Newcastle, UK' >Newcastle, UK</option><option value='Nottingham, UK' >Nottingham, UK</option><option value='Manchester, UK' >Manchester, UK</option><option value='Houston, USA' >Houston, USA</option><option value='Los Angeles, USA' >Los Angeles, USA</option><option value='New York, USA' >New York, USA</option><option value='San Diego, USA' >San Diego, USA</option><option value='Miami, USA' >Miami, USA</option><option value='Dallas, USA' >Dallas, USA</option><option value='Chicago, USA' >Chicago, USA</option><option value='Dubai, UAE' >Dubai, UAE</option><option value='Madrid, Spain' >Madrid, Spain</option><option value='Malaga, Spain' >Malaga, Spain</option><option value='Barcelona, Spain' >Barcelona, Spain</option><option value='Munich, Germany' >Munich, Germany</option><option value='Berlin, Germany' >Berlin, Germany</option><option value='Paris, France' >Paris, France</option><option value='Prague, Czech Republic' >Prague, Czech Republic</option><option value='Rio de Janeiro, Brazil' >Rio de Janeiro, Brazil</option><option value='Sao Paulo, Brazil' >Sao Paulo, Brazil</option><option value='Sao Paulo - Brooklin, Brazil' >Sao Paulo - Brooklin, Brazil</option><option value='Stockholm, Sweden' >Stockholm, Sweden</option><option value='Sydney, Australia' >Sydney, Australia</option><option value='Toronto, Canada' >Toronto, Canada</option><option value='Abuja, Nigeria' >Abuja, Nigeria</option><option value='Lagos, Nigeria' >Lagos, Nigeria</option><option value='Accra, Ghana' >Accra, Ghana</option><option value='Amsterdam, Holland' >Amsterdam, Holland</option><option value='Beirut, Lebanon' >Beirut, Lebanon</option><option value='Cork, Ireland' >Cork, Ireland</option><option value='Dublin, Ireland' >Dublin, Ireland</option><option value='Melbourne, Australia' >Melbourne, Australia</option></select></div></li><li id='field_6_2' class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex' >Name<span class='gfield_required'>*</span></label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_6_2'> <span id='input_6_2_3_container' class='name_first' > <input type='text' name='input_2.3' id='input_6_2_3' value='' aria-label='First name' aria-required="true" aria-invalid="false" /> <label for='input_6_2_3' >First</label> </span> <span id='input_6_2_6_container' class='name_last' > <input type='text' name='input_2.6' id='input_6_2_6' value='' aria-label='Last name' aria-required="true" aria-invalid="false" /> <label for='input_6_2_6' >Last</label> </span> </div></li><li id='field_6_5' class='gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_5' >Email<span class='gfield_required'>*</span></label><div class='ginput_container ginput_container_email'> <input name='input_5' id='input_6_5' type='text' value='' class='medium' aria-required="true" aria-invalid="false" /> </div></li><li id='field_6_6' class='gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_6' >Phone Number<span class='gfield_required'>*</span></label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_6_6' type='text' value='' class='medium' aria-required="true" aria-invalid="false" /></div></li><li id='field_6_12' class='gfield field_sublabel_below field_description_below gfield_visibility_visible gfsp_dot o_medium' ><label class='gfield_label' >Select Your Procedure(s) of Interest:</label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_12'><li class='gchoice_6_12_1'> <input name='input_12.1' type='checkbox' value='Hair Transplant' id='choice_6_12_1' /> <label for='choice_6_12_1' id='label_6_12_1'>Hair Transplant</label> </li></ul></div></li><li id='field_6_15' class='gfield field_sublabel_below field_description_below gfield_visibility_visible gfsp_dot o_medium' ><label class='gfield_label' ></label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_15'><li class='gchoice_6_15_1'> <input name='input_15.1' type='checkbox' value='Scalp Pigmentation (MSP)' id='choice_6_15_1' /> <label for='choice_6_15_1' id='label_6_15_1'>Scalp Pigmentation (MSP)</label> </li></ul></div></li><li id='field_6_14' class='gfield field_sublabel_below field_description_below gfield_visibility_visible gfsp_dot o_medium' ><label class='gfield_label' ></label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_14'><li class='gchoice_6_14_1'> <input name='input_14.1' type='checkbox' value='Medical Treatment' id='choice_6_14_1' /> <label for='choice_6_14_1' id='label_6_14_1'>Medical Treatment</label> </li></ul></div></li><li id='field_6_16' class='gfield field_sublabel_below field_description_below gfield_visibility_visible gfsp_dot o_medium' ><label class='gfield_label' ></label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_16'><li class='gchoice_6_16_1'> <input name='input_16.1' type='checkbox' value='Other / Not Sure' id='choice_6_16_1' /> <label for='choice_6_16_1' id='label_6_16_1'>Other / Not Sure</label> </li></ul></div></li><li id='field_6_9' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_9' >Please describe your current hair loss situation:</label><div class='ginput_container ginput_container_textarea'><textarea name='input_9' id='input_6_9' class='textarea medium' aria-invalid="false" rows='10' cols='50'></textarea></div></li><li id='field_6_10' class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_10' >CAPTCHA</label><div id='input_6_10' class='ginput_container ginput_recaptcha' data-sitekey='6Lcnf-8UAAAAAFHYojFgx4SbGd0CAW2aIU-tr2ml' data-theme='light' data-tabindex='0' data-badge=''></div></li><li id='field_6_17' class='gfield gform_validation_container field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_17' >Name</label><div class='ginput_container'><input name='input_17' id='input_6_17' type='text' value='' /></div><div class='gfield_description' id='gfield_description__17'>This field is for validation purposes and should be left unchanged.</div></li> </ul></div> <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_6' class='gform_button button' value='Submit' onclick='if(window["gf_submitting_6"]){return false;} window["gf_submitting_6"]=true; ' onkeypress='if( event.keyCode == 13 ){ if(window["gf_submitting_6"]){return false;} window["gf_submitting_6"]=true; jQuery("#gform_6").trigger("submit",[true]); }' /> <input type='hidden' name='gform_ajax' value='form_id=6&title=1&description=1&tabindex=0' /> <input type='hidden' class='gform_hidden' name='is_submit_6' value='1' /> <input type='hidden' class='gform_hidden' name='gform_submit' value='6' /> <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' /> <input type='hidden' class='gform_hidden' name='state_6' value='WyJbXSIsImM3Zjg4MzVhMWIyYjNkZmIyZTUxOTQ4YzY1ZTUxNTdhIl0=' /> <input type='hidden' class='gform_hidden' name='gform_target_page_number_6' id='gform_target_page_number_6' value='0' /> <input type='hidden' class='gform_hidden' name='gform_source_page_number_6' id='gform_source_page_number_6' value='1' /> <input type='hidden' name='gform_field_values' value='' /> </div> </form> </div> <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_6' id='gform_ajax_frame_6' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'>
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