HairGrowthMD - Secure Intake Form

To begin processing your request to obtain product, please fill in the information below. This is needed for the prescribing doctor conducting your consultation for the treatment of hair loss.

New Client?

Product currently using (please choose):

Name

First NameMiddle NameLast Name

Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Telephone Number

Format: (000) 000-0000.

Email

example@example.com

Date of Birth

Date

Gender

How long has hair been thinning:

Where on scalp:

List Medications you currently take

Rows	Medication................................	How it is taken.........................
1
2
3

Additional Medications:

Allergies to Medications

Please List Allergies

Rows	Medication...........................	Reaction............................
1
2
3

Addition Allergy information

Testosterone:

If Yes, How is it taken:

High Blood Pressure:

Describe when High Blood Pressure was discovered, treatments and status

Diabetes:

Which type of Diabetes

Heart Condition:

If Yes, Describe Heart Condition

Do you know your PSA:

Last PSA level & date tested

Enlarged Prostate:

Describe when Enlarged Prostate was discovered and severity

Prostate Cancer:

Describe when Prostate Cancer was discovered, treatment and status

Thyroid Disorder

Describe what kind of Thyroid disorder

Skin Condition:

Describe what kind of Skin condition

Are you pregnant, planning to become pregnant or nursing?

Are you still menstruating

When was last menstrual cycle?

Did you have a hysterectomy:

Please sign your full name in the box below to indicate that the given information is correct and that you consent to becoming a patient of the doctor conducting your consultation for the treatment of hair loss.