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CYG Registration Form
Thank you for your interest in Crown Your Goddess Foundation. Are you suffering from illness-related hair loss? Submit this form to register to become a CYG Member and receive FREE monthly hair loss solutions & much more!
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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Email Address
*
Your answer
Contact number
*
Your answer
Mailing Address
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Do you have illness-related hair loss/alopecia?
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Yes
No
Unsure
Other:
On a scale of 1 to 10, how much is your life impacted by your hair loss?
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least impacted
1
2
3
4
5
6
7
8
9
10
greatly impacted
Have you tried any hair loss treatments in the past?
*
Yes
No
If you answered Yes, was the treatment effective?
Yes
No
Clear selection
Thank you for applying to become a CYG Member! Upon submission of your registration form, you will be contacted with the next steps. We look forward to offering you the best solutions for your needs.
Crown Your Goddess Foundation
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