Diffuse, Patterned Alopecia ( DPA ), This patterns in this type of hair loss are essentially the same as in

more common male pattern baldness, but the areas involved do not become totally bald, the hair only
decreases in density, or might be there is a risks of fall down the transplanted hair.

By signing this form, patient acknowledge

 Doctor inform and explained about DUPA.

 My condition (DUPA) and the proposed treatment have been explained to me. I have been
advised that although good results are expected, the possibility of the transplanted hair will fall
therefore, there can be no guarantee, either expressed or implied as to the success or other
result of treatment.
 Knowing all positive and negative in the future about DUPA, patient agree to proceed with the
Hair transplant procedure.

Patient Name: _ ____________Signature: ________Date&Time:___________

Physician Name:_________________________Signature:_________________Date&Time:___________