Consultation request "(Required)" indicates required fields 1Let’s meet!2We want to know more…3Virtual or in-person consultation? For whom are you consulting today?(Required) Myself Another person First name(Required) First name Last name(Required) Last name Date of birth(Required)YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920MM123456789101112DD12345678910111213141516171819202122232425262728293031Sex at birth(Required) Male Female Are you in menopause?(Required) Not yet Premenopause Menopause Are you breastfeeding?(Required) Yes No Are you pregnant?(Required) Yes No Your weight(Required)lbs or kglbskgPhone(Required)Province(Required) AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Depuis combien d'années perdez-vous vos cheveux?(Required) Moins d’un an Moins de 6 mois Entre 6 mois et 2 ans Plus de 2 ans Votre état de santé a-t-il changé au cours des 12 derniers mois?(Required) Oui Non If yes, indicate what these changes in your health status are :Which image best reflects the current stage of your hair loss?(Required) 1 2 3 4 5 6 7 8 YOUR PICTURES (optional) Drop files here or Select files Max. file size: 300 MB. If necessary, please provide any other relevant information. (optional) Consultation request :(Required) Virtual In person Taking information to make an appointment Opening a file Consultation and hair analysis with microcamera Hair transplant consultation Consultation in capillary PRP Microscopic analysis of bulb and hair CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
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