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Online Consultation Form

Online Consultation Form

Woman

Man

None

Light

Light-Medium

Medium

Extensive

Completely

Preview

Blond

Brown

Ginger

Black

Duration

Less than 1 year

More than 10 years

Yes

As soon as possible

Within 3 months

In 1 year

I haven't planned it yet.

Yes

Name and Surname

E-Mail Address

Your Phone Number

For Gennext Pharma to be able to perform your hair analysis, please share your photos which represent your current condition.

Which medium should we use to contact you?

Phone Call

WhatsApp Message

At what time should we contact you?

From the front

From sides

From behind

Top down

You can take a look at the before-after photos of our other patients in the meanwhile.

Online Consultation Form

Preview

Choose your hair loss in the frontal area.

Choose your hair loss in the crown area.