Subscription Form

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1. CLIENT INFORMATION

Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date of Birth *

Please enter a valid date of birth as DD/MM/YYYY. Our hair loss serums are only available to patients aged 18 or over.

What was your sex at birth? *

Male
Female

Please upload a valid photo ID such as passport / driving licence *

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

Passport or national ID card: photograph the page or side with the machine-readable strip (two rows of <<< characters).
Driving licence: the front is sufficient.

2. ABOUT YOUR HAIR LOSS

Do you have a diagnosis of a specific hair loss? *

If you answered yes, please name your hair loss diagnosis

To help our trichologist assess your hair loss needs, please upload a photo of the TOP of your head

Drag & Drop Files, Choose Files to Upload

Please upload a photo of the SIDE of your head

Drag & Drop Files, Choose Files to Upload

taking... women pregnant?

Please upload a photo of the FRONT of your head

Drag & Drop Files, Choose Files to Upload

Have you lost hair elsewhere on your body? *

Yes
No
Not sure

Do you suffer from an itchy and/or flaky scalp? *

Do you suffer from Psoriasis, fungal infections such as ringwork, or dandruff of your scalp? *

Yes
No
Not sure

Do you suffer from any pain, burning/blistering or pus-filled spots on the scalp? *

When did you first start losing your hair? *

0-3 months ago
3-6 months ago
6-9 months ago
1+ Years
None of the above

How did your hair loss start? *

Suddenly
Gradually

For men only: Tick the image which most closely resembles your current stage of hair loss. *

Stage 1
Stage 2
Stage 3
Stage 3 Vertex
Stage 4
Stage 5
Stage 6
Stage 7

For women only: Tick the image that most closely resembles your current stage of hair loss *

Stage 1
Stage 2
Stage 3

3. HEALTH

Do you have any known allergies? *

If you answered yes, please list your known allergies

Do you have uncontrolled low or high blood pressure? *

Yes
No
Not sure

If you have a recent blood pressure reading, please provide this below

Do you have any of the following conditions? *

Cancer
Liver condition
Depression
Kidney or urinary condition
Hereditary problems of galactose intolerance, Lapp lactase deficiancy, or glucosegalactose malabsorption
None of the above

Do you have any of these? *

Any other significant medical conditions
Any other significant illnesses
Any significant hospital stays
Any significant past surgical procedures
None of the above

If you answered yes, please provide more details

Have you suffered from any of the following? *

Depression
Anxiety
Suicidal thoughts
None of the above

If you answered yes, please provide more information

Do you have any personal history of any cancers? *

Yes
No
Not sure

If yes, please give details of your cancer history

For men only: Are you taking medication for a prostate condition? *

For women only: Are you taking any contraceptives? *

If you answered yes, please give details of contraceptives

For women only: Have you been diagnosed with any of the following? *

Adenomyosis
Endometriosis
Fibroids
PCOS
DVT or PE (blood clots)
Any mutation of any gene (such as BRCA1/2; TP53)
Not applicable

For women only: Are you breast feeding or pregnant? *

Breastfeeding
Pregnant
Not sure
Trying to conceive
No

4. MEDICATION HISTORY

Are you currently taking... *

any topical medication
any oral medication
any recreational drugs
None of the above

If you answered yes, please list all the medication you are currently taking/using

Are you taking any non-steroidal anti-inflammatory drugs (NSAIDs)? *

Yes
No
Not sure

If you answered yes, please give details of NSAIDs

Is your partner pregnant or trying to get pregnant? *

Agreement Form *

Tick this box to confirm that you have read and signed the Terms of Agreement available at the link below.
Agreement Form