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First name (required)

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Email Address (required)

Age (required)

Address (optional)

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At what age did your hair loss start? (required)

Is the hair loss stable now? (required)

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Do you currently use any hair loss treatments? (required)

—Please choose an option—YesNo

If yes, what do you use?

Have you previously had hair transplant surgery? (required)

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If yes, when was this and what procedure did you have?

How would you class your hair loss pattern? (required)

—Please choose an option—IIIIIaIIIIIIaIIIvIVIVaVVaVIVII

How would you describe your skin colour? (required)

What is your hair colour? (required)

How would you describe your hair quality? (required)

—Please choose an option—FineMediumCoarse

How did you hear about Skin and Follicle? (optional)

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