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* =Required Field

Your name:	*
email address:	*
Verify email address:	*
Postal address:	*
Postal address line 2:
Country:	*
Your age:	*
What colour is your hair	*
Have you ever dyed your hair	No Yes Frequently *
Male or Female	Male Female *
Male degree of baldness (see chart below)	I II IIA III IIIA IIIvertex IV IVA V VA VI VII *
Female degree of baldness (see chart below)	A1 A2 A3 A4 B1 B2 *
When did the baldness first start (approx.)	1 to 2 years ago 2 to 4 years ago 4 to 6 years ago 6 to 8 years ago 8 to 10 years ago 10+ years ago *
Are you receiving or have you ever received any treatment for baldness	No Yes
If 'Yes' please explain (optional)
List any medical conditions (e.g. cardiovascular, arthritis etc.)

Treatment 750ml