Let's start with the basics, what's your name and contact email?

Medical Issues - Do you have any of the following?

Ok, now some personal questions:

Date of birth *

Gender

A few more personal questions please:

Height *

Weight *

Please list all current

prescription medications:

How quickly have you

experienced hair loss?

Are you experiencing any of the following symptoms?

Do you have, or previously had, any of the following medical conditions?

Have you had any of the following in your life recently?

The doctor may need to follow up with questions over the phone, is that ok?

Please provide phone number:

Can you share some pictures of your hair please? We'd love to take a look.

Any other info that you'd like to share with the doctor?

Do you have a preference for treatment?