Script Request

Submitting this form does not guarantee a prescription. A doctor will review your information and may contact you for further assessment before any treatment is recommended.

Script Request

Name *

First

Last

Email *

Phone *

Are you male or female? *

Male
Female

How old are you? *

Are you pregnant, trying to become pregnant or breast feeding? *

Do you have a history of heart disease? *

Are you allergic to any medication? *

Are you taking blood pressure medication? *

Do you have any significant medical history (any medical or surgical conditions that we should know about)? *

Patient Medications: Please list all medication you are currently using.

Medication you are interested in: Please let us know which medication you are interested in.

Comment or Message

Upload photos of your hair (optional)

Click or drag files to this area to upload. You can upload up to 4 files.

Contact Details

Phone: +27 21 425 7755

Email: info@mhrhairclub.co.za

Fax: +27 21 425 7835

Contact

Phone: 021 425 7755
Email: info@mhrhairclub.co.za
Fax: +27 21 425 7835

Address

4th Floor
De Waterkant Centre
9 Somerset Road
Green Point
Cape Town
South Africa
8005

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