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Dr Brad's Hair System: New Patient Form.
Please enter your details to receive your hair products.
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Email
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Your email
Full Name
*
Your answer
Date of birth
*
MM
/
DD
/
YYYY
Home address
*
Your answer
Phone number
*
Your answer
Please describe the history of your hair condition.
*
Your answer
Do any of the following apply to you
Currently pregnant
Currently breastfeeding
Planning a pregnancy in the next 3-6 months
Postmenopausal woman
If you have any other questions about the hair treatment, please write your questions below.
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