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.

YesNo

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

Name*

First NameMiddle NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Telephone Number*

Format: (000) 000-0000.

Email*

example@example.com

Date of Birth*

Date

MaleFemale

How long has hair been thinning:*

FrontCrown (top)SidesAll Over

List Medications you currently take

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

Additional Medications:

YesNo

Please List Allergies

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

Addition Allergy information

YesNo

If Yes, How is it taken:

YesNo

Describe when High Blood Pressure was discovered, treatments and status

YesNo

Type 1Type 2

YesNo

If Yes, Describe Heart Condition

YesNo

Last PSA level & date tested

YesNo

Describe when Enlarged Prostate was discovered and severity

YesNo

Describe when Prostate Cancer was discovered, treatment and status

YesNo

Describe what kind of Thyroid disorder

YesNo

Describe what kind of Skin condition

YesNoN/A

YesNo

When was last menstrual cycle?

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.*