talizi Untitled Document

Name, family name*    
Email address*    
Age *    
Color of the hair    
Hair style    
Hair diameter/type    

Please, note which picture corresponds to your condition
When hair loss started?       
Have you ever visited a doctor due to hair loss?      Yes      No  
What medications or other treatment have you used to stop hair loss?       
Initial places of hair loss       
Have you ever had transplanted hair?    Yes      No  
Please, attach photos of your head taken from different perspectives     
  Note: Max size of one picture is 2Mb. Max count of attached images is 5.  
Additional information