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Consultation for

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PRP

Follow Up

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Duration of hair loss

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Any Family History Present

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If yes

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Any Prior Treatment taken :

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If Yes :

Medical Surgical PRP Other Treatments

If Medical Treatment was taken, please write the medicines used (or) using

PRP SESSIONS

If surgical treatment was taken, please mention the details given below:

Date of the Procedure

Type of the Procedure

FUT FUE BOTH

No.of Grafts

Name of the Hospital

Are you happy with the result ?

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Any Artificial hair treatment was taken ?

No

Curling

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Hair Pieces

Wigs

If Any Cosmetic Product used(or) using:

Shampoos

Hair Oils

Lotions or Creams

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