Virtual Hair Restoration Consultation

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1. Contact Information

2. Please select photos of your hair loss patterns:*

Norwood 2Norwood 2aNorwood 3Norwood 3aNorwood VertexNorwood 4Norwood 4aNorwood 5Norwood 5aNorwood 6Ludwig 1Ludwig 2Ludwig 3

3. Which therapies have you tried? (check all that apply)*

Propecia/FinasterideRogaine/MinoxidilLaser/LLLTHair TransplantationNatural Herbs/SupplementsShampoos/TopicalsOther

4. Your Hair Restoration Goals (check all that apply)*

Hairline RestorationIncreased DensityCrown CoverageStop/Slow HairlossOther

5. Timeframe in which to proceed:*

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

6. Questions/Comments:

7. Upload Photos (Optional Max 5mb):

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