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Consultas privadas | Future Vegan

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    Nombre y Apellidos

    Fecha de nacimiento

    Email

    Teléfono

    Sexo
    masculinofemenino

    Tratamiento actual alopecia y aclaraciones

    Edad antes de empezar el tratamiento

    Duración del tratamiento

    Nacionalidad

    Antecedentes personales (antecedentes de enfermedades, quirúrgicos y tratamientos farmacológicos)

    Problemas de salud actuales (con fecha estimada de inicio)

    Tratamientos médicos y farmacológicos (incluir prescripciones crónicas)

    Alergia a la lactosa
    sino

    Problemas de infertilidad, oligospermia o desordenes hormonales
    sino

    Fotos de tu estado capilar

    Perfil izquierdo (temporal izquierdo)*
    Perfil derecho (temporal derecho)*
    Zona superior (frontal-parietal)*
    Coronilla (parietal)*

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