DIGITAL DIAGNOSTICS - Medical Hair

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Name

Name

Surname

last_name

Age

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EMAIL

E-mail

MOBILE PHONE

Phone

City

city

Province

state

NEAREST BRANCH

Headquarters

DEGREE OF BALDNESS

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FAMILY BACKGROUND

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AGE AT WHICH HAIR LOSS BEGAN

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HAIR COLOR

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HAIR TEXTURE

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MADE A CONSULTATION

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WITH WHOM

With whom

ONCE HAD A TREATMENT

Performed some treatment

Which one

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