How do you currently wear your hair? *

Shaved

Short

Mid-Length

Long

Do you understand that Scalp Micropigmentation (SMP) is a scalp tattoo and it will not regrow hair? *

Yes

No

On a scale of 1-10, how severe is your hair loss? *

1-3

4-6

7-9

10

Do you have any existing skin or scalp conditions we should be aware of? *

Yes

No

Postal code

Last Name *

First Name *

Email *

Phone *

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