Medical Questionnaire

IMPORTANT: For an adequate assessment your case, please send high resolution, detailed photos of your head/hair from all angles to Please identify your email.

Name *
Hair Loss
Please state if there is a background of hairless in your family, which family members and the degree of hair loss.
Hair Loss Progression *
Please check the treatments you are currently undergoing or medications you are taking. *
If "Other", state which.
Do you suffer from
If "Other skin conditions", state which.
If "Yes", where did you have it and who performed it?
Privacy Policy. *
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