1
About You
2
Your Hair Loss
3
Medical History
4
Shipping
Confirm Order

1 About You

About You

What was your sex assigned at birth? *

Email *

2 Your Hair Loss

Your Hair Loss

How long have you been experiencing hair loss? *

Where on your head are you experiencing hair loss? (Select all that apply)*

Do you have any of these unusual symptoms that may disqualify you for treatment:(Select all that apply) *

Have you previously tried any of the following hair loss treatments? *

Did you have any reactions to these treatments? *

3 Medical History

Medical History

What is your date of birth? *

Do you have any allergies? *

Are you taking any medications? *

Do you have or have you ever had any diagnosed medical conditions? *

Is anyone in your household currently pregnant, breastfeeding, or actively trying to get pregnant? *

Finasteride and/or Dutasteride is a Category X teratogenic medication that may potentially harm a male fetus if ingested or absorbed through the skin of a pregnant female. This risk can be mitigated by preventing the medication from coming into contact with pregnant females (avoid handling crushed or broken tablets or coming into direct contact with liquid).  You must confirm understanding/acceptance of these risks to be prescribed Finasteride and/or Dutasteride if your partner is pregnant, breastfeeding, or actively trying to get pregnant.

Do you have any customization requests? *

Is there anything else you would like to share with your doctor about your hair loss? *

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