Expected Marketing Layer Form

1

Are you 18 years or older?* This field is required.You must be 18 years or older to receive treatment. Please confirm your eligibility below.

2

Terms and Conditions* This field is required.By clicking ‘I accept’, you agree that ZyNori may use your responses to personalize your experience and other purposes as described in our Privacy Policy. Responses prior to account creation will not be used as part of your medical assessment.

3

State* This field is required.This is the state where your prescription will be shipped. If you do not see your state, we do not currently provide treatment in your area. Check back soon as we're continually expanding our coverage area.

4

What was your gender assigned at birth?* This field is required.

FEMALE

MALE

5

Nice! Looks like you're good to go on our end.

Let's continue with some questions about you and your lifestyle.

6

Which best describes your hair loss?* This field is required.Select all that apply

Thinning at the crown or top of the scalp

Widening part line

Excessive shedding, especially during brushing or showering

Receding hairline

Patchy or sudden hair loss in circular areas

7

With treatment, what results are you hoping for?* This field is required.Select all that apply

A stronger, defined hairline

Visibly thicker, fuller hair

More scalp coverage

Keep the hair I have

All of the above

8

Where are you noticing changes to your hair?* This field is required.Please select one

All over

Receding

Crown of your scalp

Multiple, defined areas

9

Losing 50–100 hairs a day is normal.

Thinning, clumps of shedding, or a widening part may signal excessive hair loss.

Early treatment can help prevent further loss and promote regrowth.

10

How much hair have you lost?* This field is required.Estimate the total amount of hair loss. Please select one.

10-30%

30-50%

more than 50%

Not sure, it's just thinner than it was

11

Telogen effluvium (sudden, diffuse shedding) is temporary hair loss often triggered by stress, medication, illness, or hormonal changes.

You may lose up to 30–50% of your hair, but regrowth usually begins within a few months once the cause is resolved.

12

When did the hair loss begin?* This field is required.Please select one

Over a year ago

In the past year

In the past few months

Not sure

13

What's your hair type?* This field is required.Please select one

Straight

Curly or coily

Wavy

Combination

14

What's your hair texture?* This field is required.Please select one

Fine

Coarse

Combination

15

Hair loss can be caused by aging, family history, and stress. Uncovering the root cause of your hair loss will help us find the right treatment for you.

16

Does hair loss run in your family?* This field is required.Please select one

Yes

No

Not sure

17

How often do you tend to experience stress?* This field is required.Please select one

All the time

Sometimes

Rarely

Not sure

18

Prescription treatments can address the root causes and help you regrow thicker, fuller hair within 3 to 6 months.

19

Now tell us about your hair routine so we can determine which treatments fit into your rhythm.

20

How do you style your hair?* This field is required.Please select one

No styling (natural hair, no heat or product)

Minimal styling (occasional use of gentle products or low-heat tools)

Moderate styling (regular use of styling tools, products or light chemical treatments)

Excessive styling (frequent heat styling, heavy product use or repeated chemical treatments)

21

Is the hair broken off or is it falling out from the follicle?* This field is required.Please select one

Breaking off

Falling out

Both

22

At ZyNori, we offer treatments with clinically-proven ingredients that stop hair loss and promote regrowth.

23

Finasteride and minoxidil are popular treatments often prescribed by dermatologists to treat hair loss.

24

Some illnesses and medications, like GLP-1, may cause temporary hair loss.

Hair typically regrows as the body recovers or adjusts.

25

Have you used or are you currently using GLP-1 weight loss medications?* This field is required.

Yes

No

26

Have you had a recent COVID infection?* This field is required.Please select one

Yes

No

Unsure

28

Preferred Treatment Option(s)* This field is required.Your weight loss plan will be a shared decision between you and your provider—your goals, preferences, and lifestyle are central to choosing the right treatment.

Oral Minoxidil (starts at $20)

Minoxidil/Tretinoin/Latanoprost/Melatonin/Sirolimus topical solution (starts at $150)

Minoxidil/Tretinoin/Latanoprost/Melatonin/Dutasterode topical solution (starts at $90)

Minoxidil/Tretinoin/Latanoprost/Melatonin topical solution (starts at $90)

29

Aside from restoring your hair, is there another area of your health you'd like to improve?* This field is required.This helps us get a full picture of your health goals and find the right treatment options for you.

Better sex

Hormone balance

Anti-aging

Weight loss

Supplement support

Lab testing

30

Is there anything else you would like your health care provider to know?* This field is required.

31

Create an account to explore treatment options.

32

Address* This field is required.Please provide your street address.

33

City* This field is required.

34

Zipcode* This field is required.

35

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