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Doctor's title

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Doctor's first name

Doctor's first name is required

Doctor's last name

Doctor's last name is required

Clinic name

Clinic name is required

Country Country is required

Language Country is required

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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