Are you over the age of 18?

• Yes
• No

What was your sex assigned at birth?

• Male
• Female

How long have you been noticing your hair loss concern?

• None as of yet, I am wanting to prevent any hair loss
• In the last year
• Over a year

Can you please select the image best describes your current hair loss concern?

Have you tried any other hair loss treatments in the past?

• Yes
• No

Are you taking any other medications? This includes prescriptions and non-prescription medications (vitamins, herbal supplements)

• Yes
• No

Do you have any medical or health issues?

• Yes
• No

16. Please attach pictures of your hair concern.

Please advise what day and time would be suitable for a video or phone consultation.

• Phone
• Video

Thank you very much, Grow Laser Cap team will be reviewing your information and we will be in contact with you shortly or please contact us now on 1800 880 160 or 0800 020 055 to discuss right away. Regards Grow Laser Cap Client Service Team.

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