Hair Loss Questionnaire
Do you have any of the following (check all that apply):
Call us at 1-877-853-0312
Hair Loss Questionnaire
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?
Call us at 1-877-853-0312
Hair Loss Questionnaire
Are you currently pregnant, breastfeeding or planning to become pregnant?
Call us at 1-877-853-0312
Hair Loss Questionnaire
Consent (pregnancy) - Read the following for more information about this product and its potential side effects:
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.
Call us at 1-877-853-0312
Hair Loss Questionnaire
Have you ever had your hair loss evaluated by a physician?
Call us at 1-877-853-0312
Hair Loss Questionnaire
Please select any of the following diagnoses that you have been given by a physician in the past
Call us at 1-877-853-0312
Hair Loss Questionnaire
Do you have any scalp conditions such as psoriasis, dermatitis, and/or recent or current scalp infections?
Call us at 1-877-853-0312
Hair Loss Questionnaire
Do you have excessive dandruff, scalp irritation, scalp redness, burning, pustules, or scarring?
Call us at 1-877-853-0312
Hair Loss Questionnaire
Are you losing hair in different parts of your body?
Call us at 1-877-853-0312
Hair Loss Questionnaire
Have you tried any treatments for hair loss before?
Call us at 1-877-853-0312
Hair Loss Questionnaire
Do you have any of the following medical conditions? (check all that apply)
Call us at 1-877-853-0312
Hair Loss Questionnaire
Do you have a history of depression, bipolar disorder, anxiety, or other mood disorders?
Call us at 1-877-853-0312
Hair Loss Questionnaire
What other information or questions do you have for the doctor?
Call us at 1-877-853-0312
Hair Loss Questionnaire
Consent (Truthfulness)
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.
Call us at 1-877-853-0312
Hair Loss Questionnaire
Consent (Hair Loss Treatment):
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.
Call us at 1-877-853-0312
Not Eligible Right Now Based On Your Answers
We understand and respect your decision not to consent to PDE5 inhibitors at this time.
These medications are a common, safe, and effective treatment for ED, as they work by improving blood flow.
If you'd like to reconsider, simply hit the back button. You can also revisit this option anytime and we're happy to provide more information and explore your choices together in a way that feels right for you.
Acknowledgement
Pharmacy Consent
