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What best describes your hair?
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Full head of hair
Receding hairline and thinning hair
Thinning and bald spots
Overall thinning
Name
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Surname
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Cell Phone
Email
*
What sort of results are you looking for?
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Regrowing my hair
Preventing future loss
Both regrowth and loss prevention
Which products would you be comfortable with?
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Only SAHPRA approved
Whatever the Doctor recommends
Don't worry - this isn't a commitment at this point. It just helps us pick the right routine for you.
Enter your birth date
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We need your date of birth to determine if you are eligible for treatment.
What is your gender?
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Male
Female
Where are you noticing hair loss?
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Widening of parting
Top of head
Overall generalised thinning
No hair loss yet
Age
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I am younger than 18 years old
I am between 18 and 45 years old
I am over 45 years old
Do you suffer from any of the following conditions? (multiple selection)
Addison’s disease
Adrenal gland disorder
Electrolyte imbalances
Gout
Heart disease
History of breast, ovarian, cervical or uterine cancer
Hyperkalemia (higher than normal amount of potassium in your blood)
Hypotension (low blood pressure)
Kidney or liver disease
Lupus or discoid lupus
Recurrent infections of the scalp
Rheumatologic conditions or autoimmune disorders
Uncontrolled thyroid problems
Scalp psoriasis
I have another medical condition
None of these apply to me
Please describe your medical condition here
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What method of birth control do you currently use (if any)?
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Birth control pills, patch, implant or ring
IUD
Condoms
Injection / shot / Depro-Provera
Partner had a vasectomy
I have had a hysterectomy or tubal ligation
I am postmenopausal and haven’t had a period in 12 months or longer
Rhythm method
Withdrawal method
Abstinence
None
Are you experiencing any of the following symptoms?
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Dandruff, itchy or flaky scalp
Pain
Burning
Spontaneous scars
Open sores
None of these
Is your hair loss related to chemotherapy?
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Yes
No
Have you ever used topical hair loss treatments?
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Yes
No
Please describe your topical hair loss treatments here
*
Have you ever had any surgeries or hospitalisation?
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Yes
No
Please describe your surgery or hospitalisation
*
Have you had any allergic reactions to any medications?
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Yes
No
Please describe your allergic reaction
*
Upload a photo of the FRONT of your head
Click or drag a file to this area to upload.
Upload a single photo, so that the Doctor can further examine the hair loss.
Upload a photo of the BACK of your head
Click or drag a file to this area to upload.
Upload a single photo, so that the Doctor can further examine the hair loss.
Is there anything else you would like our doctors to know? Please explain.
NOTICE: Spirono(lactone), Finas(teride), Dutas(teride), Minox(idil) and Tretin(oin) should not be used while pregnant or breastfeeding
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I understand.
Agreement
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I agree to the Terms and Conditions, Privacy Policy, Telehealth Consent and Read the Contra-indications.
Terms and Conditions
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