HairGrowthMD - Secure Intake Form

To begin processing your request to obtain product, please fill in the information below. This is needed for the prescribing doctor conducting your consultation for the treatment of hair loss.

New Client?

YesNo

Product currently using (please choose):

PROMOX® (with Finasteride)REMOX® (without Finasteride)

Name*

First NameMiddle NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Telephone Number*

Email*

example@example.com

Date of Birth*

Date

Gender*

MaleFemale

How long has hair been thinning:*

Where on scalp:*

FrontCrown (top)SidesAll Over

List Medications you currently take

	Medication................................	How it is taken.........................
1
2
3

Additional Medications:

Allergies to Medications*

YesNo

Please List Allergies

	Medication...........................	Reaction............................
1
2
3

Addition Allergy information

Testosterone:*

YesNo

If Yes, How is it taken:

High Blood Pressure:*

YesNo

Describe when High Blood Pressure was discovered, treatments and status

Diabetes:*

YesNo

Which type of Diabetes

Type 1Type 2

Heart Condition:*

YesNo

If Yes, Describe Heart Condition

Do you know your PSA:*

YesNo

Last PSA level & date tested

Enlarged Prostate:*

YesNo

Describe when Enlarged Prostate was discovered and severity

Prostate Cancer:*

YesNo

Describe when Prostate Cancer was discovered, treatment and status

Thyroid Disorder*

YesNo

Describe what kind of Thyroid disorder

Skin Condition:*

YesNo

Describe what kind of Skin condition

Are you pregnant, planning to become pregnant or nursing?*

YesNoN/A

Are you still menstruating*

YesNo

When was last menstrual cycle?

Did you have a hysterectomy:*

YesNoN/A

Please sign your full name in the box below to indicate that the given information is correct and that you consent to becoming a patient of the doctor conducting your consultation for the treatment of hair loss.*