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Personal Details
First Name
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Last Name
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Email
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Confirm Email
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Phone Number
Medical Details
Medical Conditions
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Do you have any of these conditions? (Please tick any that apply
None of these apply to me
Excessive thinning
Alopecia
Excema (on scalp)
Psoriasis (on scalp)
Have you received cancer treatment within the last 9 months?
*
No
Yes
Are you pregnant or have you been in the last 6 months?
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No
Yes
Do you currently have head lice or eggs?
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No
Yes
Any damage to the bottom 4cm of your hair (eg by bleaching)?
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No
Yes
Do you have any other comments, questions, or concerns?
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