Hair Loss Intake Form Pharmasave Marine Drive

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Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Personal Health Number* This field is required.Carecard number
4
Phone* This field is required.
Area Code
Phone Number
5
Birthdate * This field is required.
Month
Day
Year
6
Do you have any known allergies to medications or ingredients?* This field is required.
YESNO
7
Please specify:Please specify the severity of the allergic reaction.
8
Do you have any medical conditions?* This field is required.
YESNO
9
Please list all medical conditions:
E.g: Medical history, medical status, medications, etc.
10
Are you currently taking any medications (prescription, OTC, or supplements)?* This field is required.
YESNO
11
Please list all current medications:
Huge
Large
Normal
Small
Ok
Ok
12
Do you have a history of any of the following? (Check all that apply)* This field is required.
Liver disease
Prostate cancer or elevated PSA levels
Low blood pressure
High blood pressure
Heart disease
Scalp infections or skin conditions
None of the above
Other
13
Please specify:
Huge
Large
Normal
Small
Ok
Ok
14
Have you used finasteride or minoxidil before?* This field is required.
YESNO
15
Form (oral/topical), dose, duration, and any side effects:
Huge
Large
Normal
Small
Ok
Ok
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How long have you been experiencing hair loss?* This field is required.
< 6 months
6–12 months
1–3 years
> 3 years
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What areas are affected?* This field is required.
Receding hairline
Crown thinning
Generalized thinning
Other
18
Please specify:
Huge
Large
Normal
Small
Ok
Ok
19
Do you have a family history of hair loss?* This field is required.
YESNO
20
Select preferred product:* This field is required.
Topical Finasteride 0.1% + Minoxidil 5%
Topical Finasteride 0.05% + Minoxidil 5%
Not sure – would like prescriber to decide
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What type of topical preparation do you prefer?* This field is required.
Liquid
Gel
Foam
Not sure – would like prescriber/pharmacy to decide
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Do you consent to having your information reviewed by a licensed prescriber for treatment eligibility?* This field is required.
YESNO
23
If you do not have a prescription, would you like to consult with our affiliated prescriber? ($40 doctor fee waived)* This field is required.If No, please upload a valid prescription
YESNO
24
Please upload a valid prescription
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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25
Upload valid government-issued ID* This field is required.Driver's License, Passport, etc.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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Upload photo of scalp (optional but helpful)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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Comment or Message
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I confirm that I have provided all my health information on this form to the best of my knowledge.

I authorize a pharmacist at Pharmasave Marine Drive (1087537 BC Ltd.) to access and dispense medications according to my symptoms.

I authorize our associated Canadian-licensed physician to contact you for consultation and prescribe the medication for you.

I understand that this treatment may have risks and side effects, and I agree to follow the prescribed usage. I consent to be contacted by the pharmacy or a licensed healthcare provider regarding my request.
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Signature* This field is required.By signing below, I hereby attest that I confirm and agree to the information in this form. I attest the information provided is true and correct to the best of my knowledge and I give consent to Pharmasave Marine Drive (1087537 BC Ltd.) to assess and dispense any medications prescribed by the pharmacist.
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