Hair MDL Purchase Form

1
Please Check Circle In Appropriate Photo* This field is required.
Hairline Recession
Hairline & Crown Balding
Front & Crown Balding "Bridge" Remains
Bald, Only Rear "Fringe" Remains
Thinning Behind Hairline To Crown
No Change, Concerned About Future Hair Loss
2
Are Any Family Members Thinning or Balding?* This field is required.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.
3
Any disorders of:* This field is required.
None
Blood Pressure
Heart
Lungs
Urinary
Kidney
Blood
GI/Liver
Mental Health
Allergies to Medication
Prostate
Eyes or Endocrine
Other
4
Please list any relevant information.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
5
Are you taking any medication?* This field is required.If any, your hair related medications will be entered in the next section.
YESNO
6
Please list any medications you are taking.* This field is required.Clicking Yes and not listing your medications can result in the delay of receiving of HAIRMDL®.
Huge
Large
Normal
Small
Ok
Ok
7
PAST Oral Treatments* This field is required.Oral treatments you have tried but are not actively using. Please check all that apply.
None
Minoxidil
Finasteride (Propecia®)
Dutasteride
Spironolactone
8
PAST Topical Treatments* This field is required.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
9
PRESENT Oral Treatments* This field is required.Oral treatments you are actively using. Please check all that apply.
None
Minoxidil
Finasteride (Propecia®)
Dutasteride
Spironolactone
10
PRESENT Topical Treatments* This field is required.Topical treatments you are actively using. Please check all that apply.
None
Minoxidil
Finasteride (Propecia®)
Dutasteride
Spironolactone
Hair Laser
PRP
Hair Transplant
11
Women Only* This field is required.Required.
Men - Please check to proceed to next panel
Still having periods, pregnant, or nursing: Premenopausal
No periods: Postmenopausal
12
Patient's Name* This field is required.A red asterisk indicates a required field.
First Name
Last Name
13
Date of Birth* This field is required.
Date
Month
Day
Year
14
Your Email Address* This field is required.
example@example.com
Should be Empty: