Hair Growth Treatment Global Intake Form

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How satisfied are you with your hair overall?(Required)

Not at all

A little bit

Somewhat

Quite a bit

Very

What are your top-priority goals for hair loss treatment?(Required)

I want to prevent further hair loss

I want to regrow hair

I want fuller, thicker-looking hair

I have a full head of hair I'd like to maintain

Where are you noticing hair loss or thinning?(Required)

Both hairline and crown

Receding hairline (along my forehead or temples)

Thinning crown (top of my head)

Overall thinning

Random golf-ball size bald patches scattered all over scalp

Nowhere yet, but I'd like to prevent future hair loss

Have you ever treated your hair loss with medication?(Required)

Yes

What treatments did you receive?(Required)

Oral minoxidil

Topical minoxidil or Rogaine

Oral Finasteride or Propecia

Topical finasteride

Steroid injections in the scalp

Other

Please tell us more about your treatment experience (effectiveness, side effects, etc.).(Required)

Have you noticed any of the following?

Redness or rashes on scalp

Pain, soreness, burning, and/or tingling in areas of hair loss

Recurrent pus bumps or open sores on scalp

Partial or complete loss of eyebrows or eyelashes

Loss of body hair

None of the above

Have you ever been diagnosed with or treated for high or low blood pressure?(Required)

Yes, I have been diagnosed or treated for high blood pressure

Yes, I have been diagnosed or treated for low blood pressure

I'm not sure

Do you have, or have you ever had, any of the following conditions?(Required)

Heart failure

Pericarditis

Benign Prostatic Hyperplasia

Repeated chest pain or tightness, also called angina

Arrhythmia or abnormal heart rhythm

Coronary artery disease, or narrowing of the heart vessels

Coronary bypass surgery

Heart attack

Stroke

Pheochromocytoma (adrenal gland tumor)

Pulmonary hypertension

Prostate cancer

Kidney disease

Liver disease

Erectile Dysfunction

Anxiety

Depression

Eczema

None of the above

Please list any prescription medications, over-the-counter medications, vitamins, dietary supplements, and topical creams you are currently taking or using, including dosages. Please type N/A if none.(Required)

Are you allergic to any of the following? Please select all that apply.(Required)

Finasteride (oral or topical)

Minoxidil (oral or topical)

Ketoconazole (oral or topical)

Latanoprost

None of the above

Please list all of your known allergies. Please type N/A if none.(Required)

Is there anything else you want your doctor to know about your condition or health?(Required)

Yes

Please leave your message to your doctor here.(Required)

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Weight

Please attest to the following confirming that all information you have provided to us is true and complete. If you do not agree, you may not submit this form. Consent: I confirm that I am the patient completing this intake form and have reviewed all questions carefully. I attest that my answers are true, accurate, and complete to the best of my knowledge. I understand the importance of providing my doctor with complete and accurate health information for my care.(Required)

I agree and consent.

What is your preferred language for communication with our medical team? (¿Cuál es su idioma preferido para comunicarse con nuestro equipo médico?)(Required)

English / Inglés

Spanish / Español

First Name(Required)

Last Name(Required)

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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Stripe Setup ID(Required)

Promo Code

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Product ID

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Product Name

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Product Bundle ID

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