Intake Form

Name *

First Name

Last Name

What is the cause of your hair loss? *

Tell us about the cause of your hair loss.

Chemotherapy Treatment

Alopecia Areata

Alopecia Totalis

Burn to the Scalp

Lupus

Radiation Therapy

Styling, Coloring, or Color Correction

Natural or Premature Aging (Female Pattern Baldness, Male Pattern Baldness, Androgentic Alopecia)

Pregnancy or Postpartum Alopecia

Other

Do you have a prescription? *

A prescription is often time required. There are some exceptions, but in most cases, we will need to have your prescription on file before we can ship your product. If you don’t have a prescription, our team will use the doctor information you provide to gather any necessary prescriptions on your behalf.

Yes, I have a prescription

No, I do not have a prescription and will need help getting one.

Physicians Name *

First Name

Last Name

Physician's Phone Number *

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