What are your hair goals?
Select all that apply.
I want to regrow a receding hairline
✓
I want fuller, healthier-looking hair
✓
I want to prevent future hair loss
✓
I’m just exploring my options
✓
Medical review
Answer a few questions about your hair and health so a licensed provider can make sure your treatment is safe and appropriate for you. It takes about 5 minutes.
What was your sex assigned at birth?
Hair loss treatment differs for men and women, so we need to ask.
Do you have any of the following?
Check all that apply.
Current or personal history of prostate cancer
✓
Strong family history of prostate cancer
✓
Are you postmenopausal?
Meaning you have not had a menstrual period for 12 months or longer, or have had a surgical resection of both of your ovaries and/or uterus.
Are you currently pregnant, breastfeeding or planning to become pregnant?
Pregnancy safety consent
Please read the following carefully before continuing.
I understand that the medication prescribed to me by my healthcare provider may not be safe to take during pregnancy. For example, medications which contain finasteride are known to cause significant birth defects in a fetus and child. I acknowledge that taking this medication while pregnant could pose risks to my health and the health of a developing fetus.
I agree to take necessary precautions to avoid becoming pregnant while using this medication, including the use of effective contraception methods as discussed with my healthcare provider.
I understand that I should stop taking this medication before attempting to become pregnant. I agree to consult with my healthcare provider prior to discontinuing the medication and before planning a pregnancy to ensure my safety and well-being.
By selecting below, I confirm that I have read and understand the information provided above. I consent to proceed with the treatment under these conditions.
I have read and understand the above information, I understand the risks and wish to proceed
✓
I have read the information and do NOT wish to proceed
✓
What is your height in feet and inches?
What is your weight in pounds?
Please identify all your current medical conditions
If you have none, write "None".
Please list all your current medications including dosages
If you take none, write "None".
Please list all of your known allergies
If you have none, write "None".
Which areas are affected by hair loss?
Select all that apply.
Receding hairline (frontal)
✓
Tell us more about the pattern of your hair loss
How long have you been experiencing hair loss?
How much hair have you lost?
A little (Only I notice it)
✓
Some (Those close to me notice it)
✓
A lot (It is obvious to everyone)
✓
Do you believe your hair loss is due to:
Select all that apply.
Nutritional deficiencies
✓
Tell us more about why you think you're losing hair
Have you ever had your hair loss evaluated by a physician?
Please select any of the following diagnoses that you have been given by a physician in the past
Select all that apply.
Frontal Fibrosing Alopecia
✓
Other hair loss diagnosis
✓
I have not been given a diagnosis
✓
Please tell us more about your diagnosis
Do you have any scalp conditions such as psoriasis, dermatitis, and/or recent or current scalp infections?
Do you have excessive dandruff, scalp irritation, scalp redness, burning, pustules, or scarring?
Are you losing hair in different parts of your body?
Tell us more about your hair loss in other parts of your body
Have you tried any treatments for hair loss before?
Tell us more about your previous treatment including product use, when, duration of use, and did you experience side effects?
Do you have any of the following medical conditions?
Check all that apply.
Liver disease such as liver cirrhosis
✓
Kidney disease such as chronic kidney disease or kidney failure
✓
Heart conditions or cardiovascular diseases
✓
Pheochromocytoma (adrenal gland tumor)
✓
None of these apply to me
✓
Do you have a history of depression, bipolar disorder, anxiety, or other mood disorders?
Can you tell us more about your mood disorder and whether it is controlled or uncontrolled?
What other information or questions do you have for the doctor?
Optional. Anything else you'd like your provider to know.
Truthfulness attestation
Please attest to the following confirming that all information you have provided to us is true and complete.
I verify that I am the patient and that I have answered the questions asked in this intake form. I confirm that I have reviewed and understood all the questions asked of me. I attest that the answers and information I have provided in this questionnaire is true and complete to the best of my knowledge. I understand that it is critical to my health to share complete health information with my doctor. I will not hold the doctor or affiliated medical practice responsible for any oversights or omissions, whether intentional or not, in the information that I provided.
I have read the above information and I do consent and wish to move forward
✓
I have read the above information and I do not wish to continue
✓
Hair loss treatment consent
Please read the following information to learn more about risks and potential side effects to treatment.
Purpose of treatment
This consent applies to various medical interventions aimed at addressing hair loss in males and females. These treatments focus on slowing hair loss, stimulating new hair growth, and improving hair density and appearance. Given state restrictions, some of these products may not be offered in your area.
Treatment options
- Finasteride: An oral medication that inhibits the conversion of testosterone to dihydrotestosterone (DHT), a hormone linked to hair loss. It helps slow hair loss and may promote regrowth. This is only available for men and post-menopausal females given birth defect risk.
- Minoxidil: A topical solution that stimulates hair follicles to promote hair growth by increasing blood flow to the scalp.
- GUK-Cu: A copper peptide complex believed to enhance blood flow, support scalp health, and promote hair growth.
- Other treatments as discussed with your healthcare provider including combinations of anti-inflammatory products, caffeine derivatives, and antihistamines.
Potential benefits
- Slowing the progression of hair loss
- Stimulating new hair growth
- Enhancing the thickness and appearance of existing hair
- Improving self-esteem and quality of life
Contraindications
Certain treatments may not be suitable for individuals with:
- Finasteride: Liver disease; history of prostate cancer; allergies to finasteride or its components; women who are or may become pregnant (should not handle finasteride tablets as there is a risk for birth defects)
- Minoxidil: Scalp conditions (e.g., dermatitis, psoriasis); allergies to minoxidil or its components
- GUK-Cu: Allergies to copper peptides or its components
- General: Pregnancy or breastfeeding as certain products can cause severe birth defects; hormonal imbalances; scalp conditions or allergies to other medications or components
Potential risks and side effects
- Finasteride: Sexual dysfunction (decreased libido, erectile dysfunction); breast tenderness or enlargement; depression or mood changes; allergic reactions; possible effect on PSA levels used in prostate cancer screening; severe birth defect risk when used during pregnancy
- Minoxidil: Scalp irritation, itching, or dryness; unwanted facial or body hair growth; changes in blood pressure or heart rate (rare)
- GUK-Cu: Scalp irritation; allergic reactions
- General risks: Hormonal changes; electrolyte imbalances; mood changes or depression
Monitoring and follow-up
Regular monitoring is recommended to assess effectiveness and detect any side effects. Inform your provider of any adverse reactions or concerns.
Alternative treatments
- Hair transplant surgery
- Low-level laser therapy
- Platelet-rich plasma (PRP) therapy
- Lifestyle adjustments and acceptance of hair loss
Patient responsibilities
- Use treatments exactly as prescribed
- Report any side effects promptly
- Keep all follow-up appointments
- Inform your provider of any changes in your health status or medications
By agreeing below, you acknowledge that you have read and understood the information provided in this consent form. You agree to proceed with treatment under the conditions outlined above.
I have read the above information, understand the risks, and wish to proceed.
✓
I have read the above information and do NOT wish to proceed.
✓
✓
You're all set
Thanks for completing your consultation. A licensed provider will review your answers and follow up with your personalized treatment plan.
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We can't safely treat you online right now
Hair loss medications such as finasteride are not safe during pregnancy or while breastfeeding. Please speak with your doctor in person about options that are right for you.
Change my answer
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Treatment can't move forward without consent
We understand. Without your consent we can't provide treatment online. If you change your mind, you can pick up right where you left off.
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