Hair Loss Medical Intake Form

You have purchased a prescription product. To complete your order complete the form below and we will forward your information to one of our participating providers who can treat you from the comfort of your home.

First Name*
Last Name*
Phone Number *
Email *
Address*
City *
State Of Residence*
Zip Code*
Are you allergic to any medication? *
What medications or vitamins are you taking? *
What is your date of birth? *
Gender* Female Male
Which of the images best illustrates your hair loss? It does not have to be an exact match. *
How long have you been losing your hair?*

Do you have a family history of hair loss?*


What is your ethnicity? Male pattern baldness is much more common in some ethnicities.*




Some medical conditions can cause hair loss.*






Some symptoms indicate your hair loss may be caused by something other than male pattern baldness.*







Certain medical conditions make it unsafe to take finasteride.Select all that apply.*




We must have a clear photo of your face and your photo ID so that we may properly identify and treat you. Your information is kept strictly private. We are a HIPAA compliant website. Take a pic right from your phone or upload a photo from your computer.
Faceshot
Photo ID
Only the medical team will see your photos

Date : 09/19/2020

Note: Your medical information will not be saved until you click on the SUBMIT button.