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    Hair Loss Details

    Age when hair loss started?*

    Is the hair loss now stable?*

    How long has it been stable?

    Family history of hair loss?*

    Current Hair Treatments?*

    Previous hair surgery?*

    Norwood Hair Loss Scale:


    Please upload an image file (jpg, png, jpeg or pdf) no larger than 4MB

    Top left of the head photo:*

    Top right of the head photo:*

    Back of the head photo:*

    Front of the head photo:*

    Additional Information

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    Any other information?

    Contact Details

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    Last Name:*

    Date of Birth:*

    Email Address:*


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