Hair Loss form

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3
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5
What is your email?* This field is required.
example@example.com
6
Please upload a picture of your government issued ID* This field is required.This step is required in order for our prescribers to verify your identity and provide you with your required prescription
Drag and drop files here
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Max. file size: 10.6MB
Cancelof
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What currently describes your hair loss pattern?* This field is required.
Receding Hairline
Balding at the crown area
Not experiencing any yet, but I would like to prevent it
Overall hair loss and thinning
8
When did you first start experiencing symptoms?* This field is required.
Within one month
Within 6 months
6 months or longer
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Have you tried any medications for the purpose of hair loss treatment or prevention?* This field is required.
YESNO
10
Please list any products for hair loss you have tried in the past
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Do you have any of the following medical conditions?* This field is required.
Kidney Disease
Liver Disease
Thyroid Disease
Prostate enlargement or problems urinating
CancerHIV or autoimmune disease
Rheumatological conditions
None of these apply to me
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Unfortunately based on your answers, we are unable to provide you with a prescription. We feel you are best suited to receive the pescription from your primary care provider where you may require more frequent monitoring. Thank you for using our form!
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Are you taking any prescription, over the counter, or herbal medications? * This field is required.
YESNO
14
Please list any prescription, over-the-counter, or herbal medications you may be taking
15
Do you have a Personal or family history of prostate cancer?* This field is required.
YESNO
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Unfortunately based on your answers, we are unable to provide you with a prescription. We feel you are best suited to receive the pescription from your primary care provider where you may require more frequent monitoring. Thank you for using our form!
17
Do you have any allergies to any medications?* This field is required.
YESNO
18
Which medications are you allergic to?
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What Gender were you assigned at birth?* This field is required.
Male
Female
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Would you prefer topical or oral treatment?* This field is required.
Topical Treatments: Applied directly on to the affected areas. Less chance of side effects. Comes in a solution as well as foam.
Oral Treatments: Can be more effective, however there is increased chance of side effects. Although rare, side effects can include decreased sexual desire, reduced sexual performance and erectile dysfunction
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Choose your treatment plan* This field is required.
Finasteride 1 mg: (Same active ingredient as Propecia). Works by blocking the hormone that shrinks hair follicles, helping to keep them healthy and promoting hair growth. Cost: $55/Month
Minoxidil 2.5mg/Finasteride 1 mg: Specially compounded preparation. Oral minoxidil works for hair loss by widening blood vessels, which increases blood flow to hair follicles and helps stimulate hair growth plus the added effects of Finasteride. Cost: $70/Month
Propecia 1 mg (Brand Name): Branded form of finasteride above, however, more expensive. Cost: $90/Month
Minoxidil 2.5 mg Oral Capsule: Oral Minoxidil works for hair loss by widening blood vessels which increases blood flow to hair follicles, stimulating their growth. ** Finasteride Free Formula**. $50/Month
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Would you prefer Topical Foam or Topical Solution?* This field is required.
Topical Foam: 50 mL Foamer Bottle with 180 day expiry
Topical Spray: 50 mL Spray Bottle with 180 Day expiry. May be easier to apply for curly or wavy hair.
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Choose your treatment plan:* This field is required.
Minoxidil 10%: Topical minoxidil works for hair loss by being applied directly to the scalp, where it helps to stimulate hair follicles and promote hair growth by increasing blood flow. Cost: $70
Minoxidil 10% +Finasteride 0.25%: The added topical finasteride help hair loss by blocking the hormone that causes hair follicles to shrink, helping to maintain and promote hair growth. Cost: $80
Minoxidil 10% + Finasteride 0.25% + Biotin 0.1% + Caffeine 0.5%: The added effects of minoxidil and finasteride plus Biotin helps strengthen hair by improving its health from the inside out, while caffeine stimulates hair growth by increasing blood flow to the scalp when applied topically. Cost: $90
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Choose your treatment plan:* This field is required.
Minoxidil 10%: Topical minoxidil works for hair loss by being applied directly to the scalp, where it helps to stimulate hair follicles and promote hair growth by increasing blood flow. Cost: $90
Minoxidil 10% +Finasteride 0.25%: The added topical finasteride help hair loss by blocking the hormone that causes hair follicles to shrink, helping to maintain and promote hair growth. $95
Minoxidil 10% + Finasteride 0.25% + Biotin 0.1% + Caffeine 0.5%: The added effects of minoxidil and finasteride plus Biotin helps strengthen hair by improving its health from the inside out, while caffeine stimulates hair growth by increasing blood flow to the scalp when applied topically. $110
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Would you prefer Topical Foam or Topical Solution?* This field is required.
Topical Foam: 50 mL Foamer Bottle with 180 day expiry
Topical Spray: 50 mL Spray Bottle with 180 Day expiry. May be easier to apply for curly or wavy hair.
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Choose your treatment plan:* This field is required.
Minoxidil 5%: Topical Minoxidil works for hair loss by being applied directly to the scalp, where it helps to stimulate hair follicles and promote hair growth by increasing blood flow. Cost: $60
Minoxidil 5% + Biotin 0.1% + Caffeine 0.5%: The added effects of Minoxidil plus Biotin helps strengthen hair by improving its health from the inside out, while caffeine stimulates hair growth by increasing blood flow to the scalp when applied topically. $80
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Choose your treatment plan:* This field is required.
Minoxidil 5%: Topical Minoxidil works for hair loss by being applied directly to the scalp, where it helps to stimulate hair follicles and promote hair growth by increasing blood flow. Cost: $80
Minoxidil 5% + Biotin 0.1% + Caffeine 0.5%: The added effects of Minoxidil plus Biotin helps strengthen hair by improving its health from the inside out, while caffeine stimulates hair growth by increasing blood flow to the scalp when applied topically. $100
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Type a question
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Would you prefer pick up or delivery?* This field is required.
Pick up
Delivery
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How would you like our health care providers to contact you if further clarification is required?* This field is required.
Email
Phone Call
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Do you have any questions or concerns for our health care providers?
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Thank you for submitting your intake form. We will be in contact with you with your preferred method of contact. You will receive a notification once your medication is ready for pick up or when it is sent out for delivery. Thank you and have a wonderful day!
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