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This consultation helps our clinical team determine whether hair-loss treatment is safe and appropriate for you. Please answer all questions honestly.

Birthday
Day
Month
Year
Please confirm that you live in the UK (excluding Channel Islands).
What is your sex at birth ?
Are you pregnant, breastfeeding or likely to conceive?
Have any of the following applied in the last 12 months?
Have you experienced any of the following in the last 6 months?
Do you have any medical conditions such as :
Are you taking any of the following prescription medications?
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