Gender *

Email *

Tell us about your hair loss

Do you have any allergies? *

Are you taking any medications? *

Do you have any medical problems (e.g. high blood pressure, heart palpitations, heart failure, atrial fibrillation)? *

Have you ever taken finasteride (or Propecia)? *

Finasteride can have rare and uncommon side effects that you should be aware of. This includes sexual side effects (such as decreased libido, erectile dysfunction), and psychological side effects (such as depression or anxiety). Please see the Drug Safety Information below for more information.

Date of Birth

Have you ever used topical minoxidil (or Rogaine)? *

Are you or your partner currently pregnant, breastfeeding, or planning to get pregnant? *

Do you have any sexual performance issues? *

Do you have any kidney, heart, lung, rheumatological, liver, skin, thyroid/endocrine, eye, vascular or intestinal disorders? *

Do you currently suffer from depression? *

Do you have any customization requests for your formula? *