Intake Form - Hair Loss

Tell Us About Yourself
In order to receive your prescription, please answer these questions for our physician:

1. Personal Health Info
How did your hair loss start?*
Are you noticing hair loss or thinning?*
How would you describe the severity of your current hair loss?*
Have you ever treated your hair loss with medication?*

1. Personal Health Info
Have you noticed any of the following?*
Have you ever been diagnosed with or treated for high or low blood pressure?*
Are you and your partner trying to get pregnant in the next 3 months?*
Do you have, or have you ever had, any of the following conditions?*

List any medications, vitamin, dietary supplements, and topical creams you are currently taking or using.*
List all allergies*
What are your top-priority goals for hair loss treatment?*

2. Information for Pharmacy
Address*

Street Address

Street Address Line 2

CityState

Zip Code

3. Contact Information
Name*

First NameLast Name
Best Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Should be Empty: