Consultation form

Fantastic, you've made the right choice. Your life is about to change for the better. To place an order please fill out our New Patient Intake Form below.



Patient Information

Hair

Account Information

Your email address and the password you enter below will be used to login to our order system to track your order.


Medication

Additional Information

Patient Signature

By typing your name in the box below, you are consenting to become a patient of the doctor conducting your consultation for the treatment of hair loss.