Name-
Email (optional)-
Male Female
Age-
Age when hairloss started-
Brief description of your hair (Before treatment)

Using a number betwhen 0 (Head without hair) and 100 (Head full of Hair), Describe your -before treatment- situation

Description of your treatment (please include Concentration and other useful things)

You've started the treatment Months ago -- Years ago
Brief description of your hair now

Using a number betwhen 0 (Head without hair) and 100 (Head full of Hair), Describe your situation now

After how many months you've started notice results (If any)?
Final comments (Include side effect ecc...)