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Doctor's first name

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Doctor's last name

Doctor's last name is required

Clinic name

Clinic name is required

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Country Country is required

Language Country is required

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Device used

Yes - videodermoscope already used in clinic:

No - no device yet, but we plan to use TrichoLAB with:

Device type You can choose multiple device types or enter a type manually if it's not present on the list

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