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Welcome To Desire
Online Consultation
Complete and submit a confidential online assessment form and we will accurately assess your needs.
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7 steps!
Step 1 of 7
My Gender
Male
Female
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Step 2 of 7
Your Concern
Hair Fall
Hair Breakage
Hair Thinning
Hair Roughness
Balding Scalp Lesions
Other
Any other, Please specify
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Step 3 of 7
Are you looking for treating
Hair fall
Hair Thinning
Hair Gain/Transplant
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Step 4 of 7
What is your level of hair loss? (see the picture)
Class 1 - Receding Hair Line
Class 2 - Receding Hair Line
Class 3 – Generalized frontal thinning
Class 3V - Generalized frontal thinning
Class 4 – Frontal area & crown balding
Class 5 – Top of Scalp & crowning balding
Class 6 – Extensive hair loss
Class 7 – Severe hair loss
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Step 5 of 7
When did you first notice?
Presently
1 – 3 Months
3 – 6 Months
Other
Longer (please specify)
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Step 6 of 7
How severe is it?
Sudden and heavy
Sudden and light
Progressive
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Step 7 of 7
Family genetic history
Yes
No
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Step 8 of 7
Medical History (Is there any):
Cardiovascular
Hypertension
Diabetes
Thyroid
Renal/Kidney Problem
Psoriasis
Other
Any Other?
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Step 7 of 7
Personal Details
Full Name
Email
Phone Number
Age
Profession
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