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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.

Name:

Country:

E-mail:

Phone:

What are you using:

Viber

Skype:

Additional information

Age:

Sex:

Level of hair loss

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

Level of hair loss

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

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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or	or
or	or

Security check

Hair Loss Questionnaire

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

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

What are you using:

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

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

Have you ever undergone a hair transplant surgery?

Write your comment:

Attach photos from your computer

Enter the number from the image:

How should we contact you?

Hair Loss Questionnaire

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

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

What are you using:

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

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

Have you ever undergone a hair transplant surgery?

Write your comment:

Attach photos from your computer, or shoot photos using your webcam. How to attach or shoot photos?

Enter the number from the image:

How should we contact you?

Attach photos from your computer