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Hair Loss Questionnaire

Fill in the questionnaire, and attach photos of your head:

Contact details

Please specify your E-mail or phone number to enable us to contact you.

Additional information
Level of hair loss

Mark the drawing that corresponds most closely to your hair (when wet).


I

II

III

IIIvertex

IV

V

VI

VII
Level of hair loss

Mark the drawing that corresponds most closely to your hair (when wet).


I

II

III
Some additional questions

Have you ever undergone a hair transplant surgery?

Yes No

Write your comment:

Photographs

Attach photos from your computer

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