Please give your 3 mins to answer following questions correctly to enable us help your problem

Q1. Do You Smoke
YesNo

Q2. Your Hair loss is
Less than one yearMore than one year

Q3. Your Age
less than 25 years25 - 34 years35 - 45 Yearsmore than 45 years

Q4. Have you taken hair Loss treatment anytime in past ?
yesno

If Yes , What was duration of hair loss treatment ?
Less than 3 months3 - 6 monthsMore than 6 months

If Yes, - Was Hair Loss treatment effective ?
YesNo

Q 5. Are You suffering from diabetes (Raised blood sugar)
YouNo

Q 6. Do you have raised blood pressure ?
YesNo

Q 7. Do you have any other disease like thyroid disorder , typhoid , cancer , chemotherapy , allergy , Steroid intake etc. ? ?
YesNo

If Yes , please write here about your disease

Q 8. Any History of Allergy with anything ?
YesNo

Q 9. Do you had any surgery in past ?
YesNo

Q10. Your Preferred method of sending your image ?
EmailWhatsapp

Q 11. You want your hair transplant
within next 10 dayswithin 11 - 30 days1 - 2 months2-3 months>3 months

Full Name (Required)

Mobile no. for future Communication

Your City (required )

Your Country

E-mail ID for Communication

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