Subscription Form

Before you begin taking any hair loss medication, we require you to answer the following questions regarding your medical history.  Please answer all questions honestly and in full.  All answers are treated in strictest confidence. 

We also require that you upload one form of photographic ID such as:

• Valid passport ID page
• UK or European photocard driving licence.

You can upload your ID via the form below.

Please enable JavaScript in your browser to complete this form.

- Step 1 of 5

1. CLIENT INFORMATION

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

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Date of Birth *

(day/month/year)

What was your sex at birth? *

• Male
• Female

Please upload a valid photo ID such as passport / driving licence *

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

Next

2. ABOUT YOUR HAIR LOSS

Do you have a diagnosis of a specific hair loss? *

• Yes
• No

If you answered yes, please name your hair loss diagnosis

Have you lost hair elsewhere on your body? *

• Yes
• No
• Not sure

Do you suffer from an itchy and/or flaky scalp? *

• Yes
• No

Do you suffer from Psoriasis, fungal infections such as ringwork, or dandruff of your scalp? *

• Yes
• No
• Not sure

Do you suffer from any pain, burning/blistering or pus-filled spots on the scalp? *

• Yes
• No

When did you first start losing your hair? *

• 0-3 months ago
• 3-6 months ago
• 6-12 months ago
• 1+years
• None of the above

How did your hair loss start? *

• Suddenly
• Gradually

Next

3. HEALTH

Do you have any known allergies? *

• Yes
• No

If you answered yes, please list your known allergies

Do you have uncontrolled low or high blood pressure? *

• Yes
• No
• Not sure

If you have a recent blook pressure reading, please provide this below

Do you have any of the following conditions? *

• Cancer
• Liver condition
• Depression
• Kidney or urinary condition
• Hereditary problems of galactose intolerance, Lapp lactase deficiancy, or glucosegalactose malabsorption
• None of the above

Do you have any of these? *

• Any other significant medical conditions
• Any other significant illnesses
• Any significant hospital stays
• Any significant past surgical procedures
• None of the above

If you answered yes, please provide more information below

Have you suffered from any of the following? *

• Depression
• Anxiety
• Suicidal thoughts
• None of the above

If you answered yes, please provide more information below

Do you have any personal history of any cancers? *

• Yes
• No
• Not sure

If you answered yes, please provide more information below

Next

4. FOR MALE PATIENTS ONLY

For men only: Are you taking medication for a prostate condition?

• Yes
• No

Next

5. FOR FEMALE PATIENTS ONLY

For women only: Are you taking any contraceptives? *

• Yes
• No

If you answered yes, please specify

For women only: Have you been diagnosed with any of the following? *

• Adenomyosis
• Endometriosis
• Fibroids
• PCOS
• DVT or PE (blood clots)
• Any mutation of any gene (such as BRCA1/2; TP53)
• Not applicable

For women only: Are you breast feeding or pregnant? *

• Yes
• No
• Not sure

4. MEDICATION HISTORY

Are you currently taking... *

• any topical medication
• any oral medication
• any recreational drugs
• None of the above

yes, answered Is

If you answered yes, please list all the medication you are currently taking/using

Are you taking any non-steroidal anti-inflammatory drugs (NSAIDs)? *

• Yes
• No
• Not sure

If you answered yes, please specify

Is your partner pregnant or trying to get pregnant? *

• Yes
• No

Agreement Form *

• Tick this box to confirm that you have read and signed the Terms of Agreement available at the link below.
  Agreement Form

Submit