Registration Page

Name
Address
MM slash DD slash YYYY
Are you currently taking any medication for hair growth? (please check to indicate what you are taking)

MEDICAL HISTORY:  Do you or any immediate family member have any of the following conditions?  

For virtual appointment, we required you to fill out registration form and upload photos of your head so we can prepare your appointment.  Please click on the link below. The photos must be in these five views:

1. Full face
2. Top of head
3. Back of head
4. Right side of head
5. Left side of head
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