report-demo

Name *

Phone Number *

Email *

City *

What’s your age group? *18–2526–3536–4546+

Where are you losing the most hair? *Front hairlineCrownSides & patchesOverall thinning

How long has this been happening? *Under 6 months6–12 months1–2 years2+ years

What treatments have you tried? *Nothing yetOils, MinoxidilPRP / GFCPrevious transplant

Any health conditions or lifestyle triggers? *Hormonal deficienciesStress & lack of sleepThyroid / Vitamin DeficiencyNone

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