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DR. KLEIN'S
ORIGINAL FORMULA

Toll Free: +1(844)994-2474
Consultation

Fantastic, you've made the right choice. Your life is about to change for the better.

To place an order please fill out our New Patient Intake Form below.

Patient Information
Hair
Account Information

Your email address and the password you enter below will be used to login to our order system to track your order.

Medication
Additional Information
Patient Signature

By typing your name in the box below, you are consenting to become a patient of the doctor conducting your consultation for the treatment of hair loss.