Hair Loss

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What state do you live in?
First, we need to make sure we are licensed in your state.
What state do you live in?*
Unfortunately we cannot service this condition in your state. Please contact your local physician for assistance.
Your state may require a phone or video consultation to complete your treatment. Don't worry! Your doctor will reach out to you if this is the case.

What is your first and last name?
Name*

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What is your date of birth?
Birth Date*

MonthDayYear
You must be 18 to order this prescription medication.
today*

MonthDayYear
Date
age*

What is your gender?
What is your gender?*

Genetically MaleGenetically Female
Sorry, this treatment plan is currently only available for those genetically male.

Are you currently taking any other prescription medications?
Are you currently taking any other prescription medications?*

YesNo
Please list all prescription medications you are taking or are currently prescribed. Include all over the counter medications, vitamins, minerals, or supplements.
Please list all prescription medications you are taking or are currently prescribed. Include all over the counter medications, vitamins, minerals, or supplements.
(it is important that you list all medications you take so that your physician can evaluate if there are any concerning interactions with your requested hair loss treatment).
Many medications interact with Hair Loss medications. Your doctor wants to be sure of every medication you take. Are you SURE you do not take any other medications?
Yes: I affirm, I do NOT take any other medications.*

Yes: I affirm, I do NOT take any other medications.

When did you first notice hair loss or hair thinning?
When did you first notice hair loss or hair thinning?*

Not started yet, I’m trying to prevent itRecently within the last monthOver last 6 months to a yearOver a year
hariLossNoticeWhen-IMP*

On what areas are you experiencing hair loss or thinning?
Please select all options that apply to you.
On what areas are you experiencing hair loss or thinning?*

No significant hair loss yet, I’m trying to preventHairline (Front)Crown (top of scalp)Diffuse across entire scalpFacial hairEyebrows/eyelashesOther
Please describe any other type of hair loss you are experiencing.
Please describe any other type of hair loss you are experiencing.
Eyebrow/eyelash loss:
hairLossAreas_eye-IMP
hairLossAreas_other-IMP
hairLossAreas-IMP*

Have you ever had your hair loss evaluated by a physician and been given a diagnosis of any of the following?
Please select all options that apply to you.
Have you ever had your hair loss evaluated by a physician and been given a diagnosis of any of the following?*

Androgenetic alopeciaAlopecia areataTraction alopeciaTelogen effluviumDiscoid LupusScarring AlopeciaFrontal Fibrosing AlopeciaI have not previously had my hair loss evaluated by a physicianOther hair loss diagnosis
diagnosesHair-IMP*
otherHairDiagnosisDetails-IMP
none_1*
Please provide more details on any other hair loss diagnoses you have received.
Please provide more details on any other hair loss diagnoses you have received.*
Please uncheck 'I have not previously had my hair loss evaluated by a physician' if you have selected any other options.

Some signs and symptoms may indicate that you have other causes contributing to your hair loss aside from male/female pattern hair loss (androgenetic alopecia).

Do you have any of the following symptoms in addition to your hair loss?
Please select all options that apply to you.
Do you have any of the following symptoms in addition to your hair loss?*

Itching, burning, redness, and/or scalp tendernessBumps, sores or rashes on your scalpSudden high volume of hair loss/shedding (hair coming out in clumps daily)Smooth round patches of hair lossHair loss on other parts of my body like eyelashes/eyebrowsHair loss started during or after a major medical or life event (such as a new medical diagnosis, new medication, major life stressor/trauma, surgery or cancer therapy)I regularly wear my hair in ways that can stress my hair/scalp, including tight braids, hair weaves, locks, ponytails or I use excessive heat and chemicalsNone of the above
someSignsSymptoms-IMP*
someSignsSymptoms_additionalDetails-IMP
none_2*
Please provide any additional details about the symptoms you have selected.
Please provide any additional details about the symptoms you have selected.*
Please uncheck 'None of the above' if you have selected any other options.

Are you currently on or have you previously tried any of the following hair loss treatments?
Please select all options that apply to you.
Are you currently on or have you previously tried any of the following hair loss treatments?*

Topical Minoxidil (Rogaine)Oral MinoxidilOral Finasteride 1mg (Propecia)Oral Finasteride 5mg (Proscar)Topical FinasterideOral Dutasteride (Avodart)Topical DutasterideOther hair loss treatmentsNo prior treatments tried
treatmentResults-IMP*
OtherHairLossTreatments-IMP*
none_4*
Please provide details about 'other hair loss treatments' you have selected.
Please provide details about 'other hair loss treatments' you have selected.*
For any hair treatment(s) you used, please describe the results, and whether you intend to continue using it.
For any hair treatment(s) you used, please describe the results, and whether you intend to continue using it.*
Please uncheck 'No prior treatments tried' if you have selected any other options.

Did you experience any side effects with any of these treatments?
Did you experience any side effects with any of these treatments?*

YesNo
Please describe:
Please describe:*
treatmentSideEffects-IMP*

Do you have any issues with sexual dysfunction currently?
Do you have any issues with sexual dysfunction currently?*

YesNo
Please describe your symptoms and treatments tried:
Please describe your symptoms and treatments tried:*
hasIWSD-IMP
hasISWD_additionalDetails-IMP
Finasteride, which may be included in your hair loss treatment, has the rare potential to cause sexual side effects (in one large FDA approved clinical trial it was reported in 1.2-1.4% of cases. ). Please confirm that you understand/accept these potential risks and would like to continue with a therapy that may include these ingredients. (add link to website FAQs).
Finasteride, which may be included in your hair loss treatment, has the rare potential to cause sexual side effects (in one large FDA approved clinical trial it was reported in 1.2-1.4% of cases. ). Please confirm that you understand/accept these potential risks and would like to continue with a therapy that may include these ingredients. (add link to website FAQs).*

Yes I understand/accept and would like finasteride included in my treatment if considered appropriate by my physician.

Is your partner or spouse currently pregnant, breastfeeding, or planning to get pregnant in the next 6 months?
Is your partner or spouse currently pregnant, breastfeeding, or planning to get pregnant in the next 6 months?*

YesNo
Please describe your current situation.
Please describe your current situation.*
isCurrentlyPregnant-IMP*
pregSituationDescribe-IMP*
Finasteride is a Category X teratogenic medication that has the potential to harm a male fetus if ingested or absorbed through the skin of a pregnant female. This risk can be mitigated by preventing the medication from coming into contact with pregnant females (avoid handling crushed or broken tablets). Finasteride may also affect sperm counts/quality and can be secreted in the sperm in very low amounts, but currently there are no recommendations based on data from clinical trials to suggest that men should avoid taking Finasteride during conception or while a partner is pregnant. Please confirm that you understand/accept these potential risks.
confirm_finasteride_understanding*

Yes I confirm understanding/acceptance and would like to be prescribed finasteride if considered appropriate by my physician.I understand and I do not want to be prescribed finasteride.I have further questions for my doctor before deciding.
Questions for the doctor about finasteride and pregnancy:
Questions for the doctor about finasteride and pregnancy:*
pregFinasteride-IMP*
pregnancyQuestionsForDoctor-IMP

We understand you do not want to be prescribed right now. Thank you for your time!

In the past 3-6 months, have you been experiencing ongoing/active symptoms from any mental health condition(s)?
In the past 3-6 months, have you been experiencing ongoing/active symptoms from any mental health condition(s)?*

YesNo
Please describe the condition and if your symptoms are currently controlled with treatment/therapy.
Please describe the condition and if your symptoms are currently controlled with treatment/therapy.*
isMental-IMP*
mentalSituationDescribe-IMP*
Finasteride has the rare potential to cause psychological side effects such as mood changes, depression and anxiety. Please confirm that you understand/accept these potential risks.
confirm_finasteride_understanding*

Yes I understand and accept and would like to be prescribed finasteride if considered appropriate by my physician.I understand and I do not want to be prescribed finasteride.I have further questions for my doctor.
Questions for the doctor about finasteride and mental health issues:
Questions for the doctor about finasteride and mental health issues:*
mentalFinasteride-IMP*
mentalQuestionsForDoctor-IMP

We understand you do not want to be prescribed right now. Thank you for your time!

Do you have any allergies or intolerances to food, dyes, medications, antibiotics, or anything else?
Do you have any allergies or intolerances to food, dyes, medications, antibiotics, or anything else?*

YesNo
Please list all allergies.
Please list all allergies.*
allergiesOrIntolerances-IMP*
allergiesOrIntolerancesList-IMP*

How long ago was your most recent check up with a physician?
How long ago was your most recent check up with a physician?*

Within past yearWithin 2 yearsWithin 3-5 yearsOver 5 years ago
We do recommend that our patients have a primary healthcare provider that they see in person on regular basis. If you do not have a primary healthcare provider, you can visit Zocdoc or search federally qualified health centers to find one in your area.

Here's your first message to your doctor.
Please introduce yourself and feel free to:
- Ask any questions you have
- List any medical problem you have which were not discussed above
- Include anything else you would like the doctor to know.
Here's your first message to your doctor.*

0/0
moreToTellDoctor-IMP

Please acknowledge that you understand and agree to the following:

I have filled out a medical intake form that will be used by a board certified physician that is licensed in my state to make a medical treatment plan for me. I understand all the questions that have been asked of me. The information that I have provided is accurate and complete. I am the patient who is consenting to be evaluated for treatment.
Please acknowledge that you understand and agree to the following:*

I acknowledge and agree to the above.

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Please provide a picture of the top of your head and of you facing forward*

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Medications we offer:
Finasteride (Generic Propecia)*

Finasteride 1mg, 3 month supply for $90.00Finasteride 1mg, 6 month supply for $162.00 (10% savings!)Finasteride 1mg, 12 month supply for $252.00 (30% savings!)
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What state do you live in?

What is your first and last name?

What is your email?

What is your phone number?

What is your date of birth?

What is your gender?

Are you currently taking any other prescription medications?

When did you first notice hair loss or hair thinning?

On what areas are you experiencing hair loss or thinning?

Have you ever had your hair loss evaluated by a physician and been given a diagnosis of any of the following?

Some signs and symptoms may indicate that you have other causes contributing to your hair loss aside from male/female pattern hair loss (androgenetic alopecia).

Do you have any of the following symptoms in addition to your hair loss?

Are you currently on or have you previously tried any of the following hair loss treatments?

Did you experience any side effects with any of these treatments?

Do you have any issues with sexual dysfunction currently?

Is your partner or spouse currently pregnant, breastfeeding, or planning to get pregnant in the next 6 months?

We understand you do not want to be prescribed right now. Thank you for your time!

In the past 3-6 months, have you been experiencing ongoing/active symptoms from any mental health condition(s)?

We understand you do not want to be prescribed right now. Thank you for your time!

Some medical conditions can contribute to hair loss and some can make it unsafe for you to use certain hair loss treatments. Please provide details of any diagnosed medical conditions you have or have had in the past .

Do you have any allergies or intolerances to food, dyes, medications, antibiotics, or anything else?

How long ago was your most recent check up with a physician?

Here's your first message to your doctor.

Please provide a picture of the top of your head and of you facing forward.

Medications we offer: