12345Now, let's get you started.Personal InformationFirst NameSurnamePhone NumberEmail AddressDate of BirthAddressBy completing this form, you agree to receive communications from HairyHair about our hair loss products and services, including access to our licensed health practitioners. Your information will only be used to provide personalised recommendations. You can unsubscribe at any time.NextWhat is your age group?Under 2525 - 3435 - 4445 - 5455+How long have you been experiencing hair loss?Less than 6 months6 months to 1 year1 - 2 years2+ yearsWhich of the following best describes your current level of hair loss?Mild thinningNoticeable PatchesSignificant lossNearly baldPreviousNextHave you tried any hair loss treatments before?Yes, and I'm currently using themYes, but I’ve stoppedNo, I haven’t tried any treatmentsHow committed are you to finding a solution for your hair loss?Very committed, I’m ready to startSomewhat committed, I’m still exploring optionsNot very committed, just curiousPreviousNextWhat results are you hoping to achieve with a hair loss treatment?Slowing down further hair lossRegrowing lost hairBothHow soon are you expecting to see results from a hair loss treatment?1 - 3 months3 - 6 months6+ monthsI’m willing to wait as long as it takesAre you willing to follow a daily routine for taking the pill?Yes, absolutelyMaybe, if it’s easy to rememberNo, I’m not good with routinesPreviousNextDo you have any known allergies or sensitivities to medications or supplements?YesNo[group yesalregies clear_on_hide]Please Explain[/group]Are you currently taking any other medications or supplements?YesNo[group yesmedicine clear_on_hide]Please Explain[/group]Do you have a history with high blood pressure (related to using minoxidyl) or prostate?YesNoUnsure[group yeshistory clear_on_hide]Please Explain[/group]Previous Loading... Now, let's get you started.Personal Information For most, this takes about 2 minutes. First Name Surname Phone Number Email Address Date of Birth Select GenderMaleFemale Address By completing this form, you agree to receive communications from HairyHair about our hair loss products and services, including access to our licensed health practitioners. Your information will only be used to provide personalised recommendations. You can unsubscribe at any time. Next 1Hair DetailsThese details are required so the doctor can provide the best solution.What is your age group? Under 25 25 - 34 35 - 44 45 - 54 55+ How long have you been experiencing hair loss? Less than 6 months 6 months to 1 year 1 - 2 years 2+ years Which of the following best describes your current level of hair loss? Mild thinning Noticeable Patches Significant loss Nearly bald Which of the following best describes your current level of hair loss? Mild thinning Noticeable Patches Significant loss Nearly bald What results are you hoping to achieve with a hair loss treatment? Slowing down further hair loss Regrowing lost hair Both Next 2Medical DetailsThese details help us determine if Hairy Hair is right for youDo you have any known allergies or sensitivities to medications or supplements? Yes No Please ExplainAre you currently taking any other medications or supplements? Yes No Please Explain Do you have a history with high blood pressure (related to using minoxidyl) or prostate? Yes No Unsure Please Explain Submit
