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Consultation Form
Full name
Date of birth
Email address
Sex
male
female
Where have you noticed hair thinning or loss?
How long have you had hair loss or thinning?
less than 1 year
between 1 and 3 years
longer than 3 years
Have you been diagnosed with alopecia or any skin conditions?
*
no
yes
Does anyone in your family suffer from hair loss?
*
yes
no
Do you have any health issues or illnesses?
*
no
yes
If yes, please detail any medical complaints here
Please list any medications that you currently take
Do you have any allergies?
no
yes
If yes, the please detail your allergies
