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Are you worrying about your hair condition?
Are you interested in our treatment?
Take our online survey to find out if it’s right for you.
The form takes less than 3 minutes to complete.

Your Name (required)

Your Email (required)

Confirm Email (required)

 Male Female

What is your hair loss history?

What is your age?

are you currently experiencing hair loss?
 Under 25% 25% to 50% 50% to 75% Over 75% Just started thinning No hair loss

Have you had any previous treatments?

what is your hair type?
 Caucasian African Asian

Are you under constant pressure or stress?
 Yes No

Do you work in an environment that exposes you to chemicals on a daily basis?
 Yes No

Do you use any chemicals on your hair? (eg. hydrogen peroxide, perm solutions, colorings, relaxers or any others)
 Yes No

If you answered yes, please list which ones

Do you have any of the following conditions?

Other conditions, or expand on previous answer?

What type of diet do you have?

Has your weight changed dramatically in the last 12 months?
 Yes No

Anything else you would like to add?


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