Eflornithine Cream Request

Facial Hair Reduction Cream Request

Answer a few questions so your provider can screen whether this treatment is a good fit for you.
About You
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
Mobile Phone
Please enter a valid phone number.Format: (000) 000-0000.
Shipping Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Current TMC Member?
Your Facial Hair
Location of unwanted hair

Other
If other, please describe
How long has the unwanted hair been noticed?
Did it appear suddenly or get much worse quickly in the last few months?
Recent symptoms (select all that apply)
Have you ever been diagnosed with PCOS or another hormone condition?
If yes, please describe the condition
How do you currently remove the hair?
Health History
Do you currently use testosterone or DHEA?
Are you pregnant, trying to get pregnant, or breastfeeding?
Do you have an allergy to eflornithine or parabens such as methylparaben?
Do you currently have cuts, sores, infection, or broken skin on your face?
Current medications and supplements
Other allergies
Acknowledgements
Acknowledgements
Electronic Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Facial Hair Reduction Cream Request