Treatment Options

1
What is your full name?* This field is required.
First Name
Last Name
2
What is your date of birth?* This field is required.
Date
Month
Day
Year
3
What is your sex assigned at birth?* This field is required.
Male
Female
4
Email* This field is required.
example@example.com
Confirm Email
5
Phone Number* This field is required.
Please enter a valid phone number.
6
What is your mailing address?* This field is required.
Street Address
Street Address Line 2
City
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Country
7
We're sorry, but our services are currently only available to residents of Florida.
8
Which areas are affected by hair loss? (Select all that apply)* This field is required.
Scalp
Eyebrows
Beard
Body hair
Other
9
Please specify the affected areas.* This field is required.
10
When did you first notice hair loss?* This field is required.
Less than 3 months ago
3-6 months ago
6-12 months ago
Over a year ago
11
How has your hair loss progressed since it began?* This field is required.
Stable
Gradually worsening
Rapidly worsening
12
Is there a family history of hair loss?* This field is required.
Yes
No
Unknown
13
Please specify which family members have experienced hair loss.* This field is required.
14
Have you tried any treatments for hair loss?* This field is required.
YESNO
15
Please specify the treatments you've tried and their results.* This field is required.
16
Do you have any of the following conditions? (Select all that apply)* This field is required.
Thyroid disorders
Autoimmune diseases (e.g., alopecia areata, lupus)
Hormonal imbalances
Nutritional deficiencies
Scalp infections
None of the above
17
Have you experienced any of the following recently? (Select all that apply)* This field is required.
Significant weight loss
High-stress levels
Recent surgery or illness
Pregnancy or childbirth
None of the above
18
Is your hair loss accompanied by pain, itching, or scalp lesions?* This field is required.
YESNO
19
Have you noticed sudden or patchy hair loss?* This field is required.
YESNO
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