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Name
Email
Phone
How would you describe the current state of your hair? (Select all that apply)
Thinning at the crown
Receding hairline
Noticeable bald spots
Overall thinning
No significant hair loss
None
When did you first start noticing hair loss?
Less than 6 months ago
6-12 months ago
1-3 years ago
Over 3 years ago
None
Have you tried any hair loss treatments or solutions before?
Yes, currently using
Yes, in the past
No, never tried
None
Do you have a family history of hair loss?
Yes, on my mother's side
Yes, on my father's side
Yes, on both sides
No, not that I'm aware of
None
What is your desired outcome for hair loss?
Restoring full hair coverage
Achieving a natural-looking hairline
Minimizing further hair loss
Partial improvement is acceptable
None
Time's up
