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Welcome to HAIRMDL® for Men
For the Men's formula of HairMDL® only.
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1
Full Name
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First Name
Last Name
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2
Address
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Street Address
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Serbia
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Switzerland
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Timor-Leste
Togo
Tokelau
Tonga
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Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
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Vatican City
Venezuela
Vietnam
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Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
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3
Email Address
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Please enter your email address.
example@example.com
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4
Phone Number
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Area Code
Phone Number
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5
Please Select Your Birthdate
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Date
Year
Month
Day
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6
Are you taking any medication?
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If any, your hair related medications will be entered in the next section.
Yes
No
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7
If yes, please list any medications you are taking.
Clicking Yes and not listing your medications can result in the delay of receiving of HAIRMDL®.
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8
Do you have any allergies?
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YES
NO
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9
If yes, please list any allergies.
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10
Any disorders of:
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None
Blood Pressure
Heart
Lungs
Urinary
Kidney
Blood
GI/Liver
Mental Health
Allergies
Prostate
Eyes or Endocrine
Other
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11
If you answered yes to of those disorders, please list any relevant information.
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12
PAST Topical Treatments
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Topical treatments you have tried but are not actively using. Please check all that apply.
None
Minoxidil
Finasteride (Propecia®)
Dutasteride
Spironolactone
Hair Laser
PRP
Hair Transplant
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13
PRESENT Topical Treatments
*
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Topical treatments you are actively using. Please check all that apply.
None
Minoxidil
Finasteride (Propecia®)
Dutasteride
Spironolactone
Hair Laser
PRP
Hair Transplant
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14
PAST Oral Treatments
*
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Oral treatments you have tried but are not actively using. Please check all that apply.
None
Minoxidil
Finasteride (Propecia®)
Dutasteride
Spironolactone
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15
PRESENT Oral Treatments
*
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Oral treatments you are actively using. Please check all that apply.
None
Minoxidil
Finasteride (Propecia®)
Dutasteride
Spironolactone
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16
Please select the Affected Areas On Your Scalp
Please check all that apply.
Thinning Front Hairline
Thinning Sides
Thinning Crown
Not Noticeable Yet - Concerned
Other
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17
Are Any Family Members Thinning or Balding?
Please check all that apply.
Mother
Father
Siblings (if any)
No
Maternal Grandfather (Mother's Side)
Maternal Grandmother (Mother's Side)
Maternal Grandfather (Father's Side)
Maternal Grandmother (Father's Side)
None of the Above / Other Family Members
Not Sure.
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18
What Age Were You When You Noticed Hair Loss?
*
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Approximately...
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19
The Front of Your Head
Please make sure the photos are clear.
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20
Please use the camera to capture the front of your head.
*
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You may have to scroll down to see the TAKE PHOTO button.
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21
The Top of Your Head
Click NEXT and use your camera to capture the top of your head.
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22
Please use the camera to capture the back of your head.
*
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You can lean forward and capture your crown that way. You may have to scroll down to see the TAKE PHOTO button.
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23
The Side of Your Head
Click NEXT and use the camera. You may have to scroll down to see the TAKE PHOTO button.
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24
Please use the camera to capture the side of your head.
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You may have to scroll down to see the TAKE PHOTO Button.
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25
The Other Side of Your Head
Click NEXT and use the camera to capture the other side of your head.
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26
Please use the camera to capture the other side of your head.
*
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You may have to scroll down to see the TAKE PHOTO Button.
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27
Please use the camera to capture the front of your legal photo ID.
*
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All images and vital text must be legible. You may have to scroll down to see the TAKE PHOTO button.
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28
Please use the camera to capture the back of your legal photo ID.
*
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All images and vital text must be legible. You may have to scroll down to see the TAKE PHOTO button.
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29
THANK YOU! PLEASE CLICK SUBMIT TO PURCHASE YOUR PRODUCT!
*
This field is required.
Upon purchase Dr. Feinberg will evaluate your response and you will receive notification within 48 hours.
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