Contact Information

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First Name Last Name

Phone Number Email

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GenderMaleFemale Age

Help Us Understand Your Hair Loss

Please select photos of your hair loss patterns:*

Norwood 2
Norwood 2a
Norwood 3
Norwood 3a

Norwood Vertex
Norwood 4
Norwood 4a
Norwood 5

Norwood 5
Norwood 6
Ludwig 1
Ludwig 2

Ludwig 3

Which treatments have you tried? (check all that apply)*

Propecia/FinasterideRogaine/MinoxidilLaser/LLLTFUT Hair Transplant and FUE Hair TransplantNatural Herbs/SupplementsShampoos/TopicalsOther

Hair Restoration Goals (check all that apply)*

Hairline RestorationIncreased DensityCrown CoverageStop/Slow Hair-lossOther

Treatment Timeframe:*

Select TimeframeWithin 0-2 months3-6 months6-9 months9-12 months12+ months

Questions/Comments

Photo submission (Optional Max 5mb):

Instructions: Please follow these examples for the angles of your head needed for evaluation. All submitted images and information will be kept confidential, not be used or sold by any third parties, nor be broadcast publicly.

Angle 1
Angle 2
Angle 3

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