HAIR LOSS TREATMENT FORM

Please complete our online intake form below.

This allows our doctor to review your file and approve you for any treatments deemed safe and appropriate for your hair treatment needs.

After submitting the form, please follow the link and pay the R400 doctor consultation fee.

Our medical team will contact you within a few days to discuss the way forward.

First Name(Required)

Last Name(Required)

Gender(Required)

Date of Birth(Required)

DD slash MM slash YYYY

Email(Required)

Phone No(Required)

Emergency Contact Name(Required)

Emergency Contact Number(Required)

Emergency Contact Relationship(Required)

Primary Doctor's Name

Primary Doctor's Contact No

What is your height (cm) ?(Required)

What is your weight (Kg) ?(Required)

What best describes your hair?(Required)

Hairline receding

Thinning at the crown

Overall hair loss and thinning

100% bald

No hair loss yet

When did you first notice your hair loss?(Required)

Within the last 3 months

6 months to 1 year ago

1 year to 2 years ago

·More than 2 years ago

I want to prevent hair loss

What results are you looking for?(Required)

Prevent additional hair loss

Hair regrowth and improve hair volume

Both regrowth and hair loss prevention

Does anyone in your family have hair loss?(Required)

Yes on my mother’s side

Yes on my father’s side

Other

Please provide details of who in your family has hair loss.

Which of the following treatments have you used to treat your hair loss in the past?(Required)

Tropical Minoxidil solution or foam

Oral Finasteride 1 mg or 5 mg

Topical Finasteride 0.1% or higher

Dutasteride

Hair loss shampoos (e.g. Nioxin or Alpecin)

Other topical treatments

Other

None

For each treatment that you have tried, how effective was it in treating your hair loss?

Did you at any time, experience side effects from your treatments for hair loss?

No, I never experienced any side effects

Yes

Do you have any allergies or medication reactions?(Required)

Yes, I am allergic to some foods

Yes, I am allergic to some medicines

No, I have no allergies or medication reactions

Other

Please list what you are allergic to and the reaction that each allergy causes?

Do any of the following apply to you?(Required)

Admitted to hospital in past 5 years

Had an anaesthetic or surgery in past 5 years or have a history of prior surgeries

Taken any chronic prescription or OTC medication in past 2 weeks

Been diagnosed with cancer or malignancy

Been diagnosed with HIV or AIDS

Your parents have any chronic medical conditions and/or is there a history of sudden cardiac arrest in your family?

None apply to me

Which of the following apply to you?(Required)

I would describe myself as physically fit

I experience breathlessness or chest pain when performing daily activities

I get less than 3 hours of exercise a week

I do not eat as healthily as I would like

I smoke or use tobacco (e.g. chewing tobacco, snuff)

I use other nicotine containing products (e.g. vaping)

I drink more than 2 alcoholic drinks per day

On average, I get less than 6 hours sleep per night

I am more than 12 kgs overweight

I am under a lot of stress

None apply to me

Have you experienced any of the following conditions or symptoms?(Required)

Sudden and significant increase in shedding

Hair loss other than on your scalp

Itching, pain, burning or bumps on the scalp

Red rings or rashes on the scalp

A diagnosis of scalp psoriasis or scalp eczema

Skin rashes on an ongoing basis

A diagnosis of recurrent chronic fungal or yeast infections

Suffer from dry skin

Joint pain on an ongoing basis

Rheumatological disorders or autoimmune disease (e.g. lupus, discord lupus, sar-coidosis, psoriatic arthritis

None apply to me

Have you been diagnosed with or experienced any of the following conditions or symptoms?

A change in appetite or weight in the past 6 months which has not been intentional

A diagnosis of raised blood sugar levels and/or formal Diabetes Mellitus

A significant change in the hair on the rest of your body (not head or face) in past 6 months

A significant change in energy levels in the past 3 months

Liver disease

Renal or Kidney disease

Thyroid disease

Increased blood pressure

Raised cholesterol and/or triglyceride levels

Palpitations (the sensation of your heart beating)

Episodes of syncope (fainting) or severe dizziness on sudden standing

Angina and/or heart attack

Cerebral aneurysm

Transient ischaemic attack (TIA) or a stroke

Abnormal heart rhythm (arrhythmia)

Bleeding problem or tendency

A diagnosis of having asthma, chronic bronchitis, and/or chronic obstructive pulmo-nary disease (COPD)

A diagnosis of obstructive sleep apnoea

Snoring loudly enough to wake your spouse or partner

Very tired during the day despite an adequate amount of sleep

Depression or major depressive disorder

Anxiety or panic disorder

Psychiatric condition (e.g. Schizophrenia, bipolar disorder, personality disorder)

History of suicidal thoughts or plans to hurt yourself

Under a lot of stress currently

None apply to me

Which treatment plan is best suited to your budget?

R650 (Personalized treatment, Free delivery, Ongoing doctor care)

R790 (Personalized treatment, Growth stimulating shampoo, Free delivery, Ongoing doctor care)

R1 300 (Personalized treatment, Growth stimulating shampoo, Moisturizing conditioner, Free delivery, Ongoing doctor care)

R2 500 (Peptide Combo Hair Rescue)

Because every treatment plan is personalized for you by the doctor, these prices are just an estimate.

Please take and upload photos of the following profiles of your hair

File

Max. file size: 512 MB.

Consent(Required)

Agreement to our terms and conditions

I have read and agree to the content of this consent document

Name

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