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Which area(s) of your scalp are affected by hair loss? *

Front head

Bald spots / thinning

Vertex / crown thinning

Diffuse thinning

Select from above

How long have you been experiencing hair loss? *

Have you received any previous medical or surgical treatments for hair loss? *

Have you received any previous medical or surgical treatments for hair loss?

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What is your age? *

Full Name *

Email *

Phone *

What’s your postcode? *

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