Please select your gender first:*
This is to make sure we ask the right questions.
MaleFemale

First Name*

Last Name*

Email Address*

Phone Number*

Did you lose your hair suddenly or gradually? *
GraduallySuddenly

Select the hair loss stage which best describes your current hair loss pattern: *
Male Hair Loss ScaleFemale Hair Loss Scale

---IIIII-AIIIIII-AIII-vertexIVIV-AVV-AVIVIICompletely Bald HeadOverall Thinning

---12345678Completely Bald HeadFrontalOverall Thinning

Knowing there is no cure for hair loss yet, will you be happy to stop your hair loss progression and see steady improvement to your hair density over time?
YesNo

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