Hair Loss

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The Power of Prescription Hair Care

Your privacy is very important. The following information is only used to assess your hair care goals, determine what treatments are appropriate for your condition and to avoid any possible reactions.
Our Process

Completing this form allows our expert pharmacists to:
1. Evaluate your needs.
2. Create your individualized medical-grade hair care regimen.
3. Send the prescription to your provider for an approval.
We won’t contact you for payment until your prescription has been approved by a provider.
Full Name*

First Last
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
We will never SPAM or sell email addresses to third parties.
Phone:*
ex. 555-555-5555
Gender*

FemaleMaleOther
Birthdate: (You must be over 18)*
ex. 01/05/1960
What is the best way to contact you?*

Phone callEmailTextAll
Are you allergic or sensitive to anything?*

NOYES
If yes, please list sensitivities and/or allergies:
If yes, please list area(s):
Have you had any of these health conditions in the past or present? *

High blood pressureEnlarged prostateHyperthyroidismHypothyroidismGastric bypassHormone imbalanceCancerNONEOther
Do you have alopecia (hair loss) ?*

NOYES
If you have alopecia, please describe:
Have you had a recent COVID infection?*

NOYES
If you have had a recent COVID infection, please provide the date you think you were infected

MonthDayYear
Date
List all oral VITAMINS or HERBS you take daily:*
Are you allergic or sensitive to any of the following medications?*

TretinoinMelatoninFinasterideRosemaryLatanoprostMinoxidilBimatoprostDutasterideNONEOther
Female Clients
Are you pregnant or trying to become pregnant?

NOYES
List any additional conditions you would like treated:
Do you already have a prescriber that ProCompounding Pharmacy can send a recommendation to?

YesNo
Provider's name:
Provider's phone number:
Photos that will be beneficial in evaluating your hair care needs. *

Cancelof
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the provider of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release ProCompounding Pharmacy and/or the provider from liability and assume full responsibility thereof.*

I understand.
OPTIONAL: I grant permission to ProCompounding Pharmacy to use photos of my progress for marketing purposes business listing pages such as Instagram.

I grant permission.
Date*

MonthDayYear
Please upload current picture identification (drivers license, state identification, passport, etc...)*

Cancelof
Signature*
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The Power of Prescription Hair Care