Hair Medication Consultation Form

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Let's get started!

Do you agree to the following?

I'm an Australian Resident, 18 years or over.
I agree to the terms and conditions and privacy policy.

Now, let’s get personal.

Full Name

Date of Birth

Phone Number

Birth Gender

Female
Male

Are you trying to conceive, pregnant, or breastfeeding?

⚠️ Unfortunately, prescription hair treatments are not suitable for those pregnant or breastfeeding. We recommend our natural alternative > Stimulating Growth Tonic

Thanks! Now we need to know...

Do you have any medical conditions?

Are you currently taking any medications or supplements?

Do you have any known allergies?

Now for the reason you're here.

How would you describe your hair loss pattern?

When did you first notice hair loss?

Less than 6 months ago
6 months to 1 year ago
Over a year ago

Have you previously used any hair loss treatments?

Also...

Do you smoke or vape?

Is there anything else you'd like us to know about your hair loss or overall health?

And finally...

I acknowledge that my consultation will be reviewed by a qualified practitioner, that treatment is subject to clinical approval and I have answered the above questions accurately and honestly.