1 2 3 4 5 Now, let’s make it personal. Personal Information First Name Surname Phone Number Email Address 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 What 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+ years Which of the following best describes your current level of hair loss? Mild thinningNoticeable PatchesSignificant lossNearly bald PreviousNext Have you tried any hair loss treatments before? Yes, and I'm currently using themYes, but I’ve stoppedNo, I haven’t tried any treatments How 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 curious PreviousNext What results are you hoping to achieve with a hair loss treatment? Slowing down further hair lossRegrowing lost hairBoth How 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 takes Are you willing to follow a daily routine for taking the pill? Yes, absolutelyMaybe, if it’s easy to rememberNo, I’m not good with routines PreviousNext Do you have any known allergies or sensitivities to medications or supplements? YesNo Please Explain Are you currently taking any other medications or supplements? YesNo Please Explain Do you have a history with high blood pressure (related to using minoxidyl) or prostate? YesNoUnsure Please Explain Previous
