Which 'HAIR THINNING' Treatment Is Right For Your Specific Hair Loss Type?
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Take a Hair Questionnaire
1. Basic Info
2. State of Your Hair Health
3. History of Hair Treatments
4. Upload Your Hair Photos
Hair Survey
1. Your Information
FIRST NAME
*
LAST NAME
*
PHONE
EMAIL
*
DATE OF BIRTH
STREET ADDRESS
ADDRESS LINE 2
CITY
STATE
ZIP
2. Hair / Health Profile
WHEN DID YOU FIRST NOTICE YOU WERE LOSING HAIR?
HAVE YOU EVER USED ROGAINE
PLEASE SELECT
Yes
No
HAVE YOU EVER BEEN PRESCRIBED AND USED PROPECIA?
PLEASE SELECT
Yes
No
DO YOU TAKE ANY MEDICATIONS ?
DO YOU HAVE ANY EXISTING MEDICAL CONDITIONS OR ILLNESSES?
DO YOU SMOKE?
HAVE YOU HAD A HAIR SURGERY IN THE PAST?
TELL US ABOUT HAIR LOSS ON YOUR MOTHER'S SIDE OF YOUR FAMILY.
TELL US ABOUT ANY HAIR LOSS EXPERIENCED BY YOUR BROTHERS OR SISTERS.
3. Your Hair Procedure
SELECT THE AREAS OF YOUR SCALP WHERE YOU NEED HAIR RESTORATION
Front
Top
Small Crown
Expanded Crown
4. Upload your photos
Front Photo
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Front Photo
Maximum upload size: 1MB
Top Photo
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Top Photo
Maximum upload size: 1MB
Left Photo
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Left Photo
Maximum upload size: 1MB
Right Photo
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Right Photo
Maximum upload size: 1MB
Back Photo
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Right Photo
Maximum upload size: 1MB
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Meet Dr. Rapaport
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Platelet-Rich Plasma Hair Restoration
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Take a Hair Questionnaire
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