Choose your Location

What is your date of birth?

Please list the medications you have previously used, as well as the dosage and side effects

When did you first notice hair loss?

Less than 6 monthsMore than 6 months

Was the hair loss gradual or sudden?

Hair loss was gradualHair loss was sudden

How quickly did you notice your hair loss?

Do you have a family history of hair loss?

YesNoI’m not sure

Do you have any of these conditions?

Rheumatological disorders including lupus or psoriasisSkin conditions including atopic dermatitis, seborrheic dermatitis, contact dermatitisMajor physical or emotional stressThyroid conditionEating disorderSevere dietary restrictionsNone

Tell us more about your condition? How long have you had it? How is it related to your hair loss? What restrictions do you have?

Have you had any other problems with the scalp, hair loss (elsewhere on the body), or hair loss after use of prescription medicine

Itching, burning, and/or scalp tendernessUnusual bumps or rashes underneath my hairMy hair loss began before pubertyI have complete hair loss on other parts of my body, like my eyebrows and eyelashesI have complete hair loss over my entire scalp (including the very back of the head)My hair loss started during or after a medical treatment, such as a new prescription or cancer treatmentI regularly wear my hair in ways that can stress my hair and scalp, including tight braids, hair weaves, cornrows, and ponytails, or often use excessive heat and chemicalsNone of the aboveOther

Tell us more about your condition

Do you have any of the following health issues?

Liver abnormalitiesDifficulty urinatingHave or have had prostate cancerHave or have had breast cancerHeart disease or heart attackOpen heart surgery or heart stentNoneOther

Tell us more about your condition like When were you diagnosed? When did it happen?

Are you allergic to any medicines?

YesNo

Enter medicines

Are you currently taking any medicines? Include vitamins, herbs, and over-the-counter products, like pain relievers and sleep aids.

YesNo

Enter medicines including names, dose, frequency, and reason for taking. Names: Dose: Frequency Reason for Taking:

Anything else you would like us to know?

YesNo

Tell us about any concerns or questions you have for the medical team.

How would you like to pay?

Out of pocketInsuranceupload emirates insurance details (if available) Upload a Photo of your Emirates ID Upload Front Upload Back

Billing and delivery details

Google MapDelivery Location Google Map: (Please Share your Google Map Link) Delivery Location Neighborhood/Area: Street Name/No: Address Details:

Personal Details

Title: First Name: Last Name: Mobile Number: E-mail:

Confirm Request and Agree to Terms

After you submit your request, a licensed medical provider will review your information. You will be notified by email/contact number when that provider has reviewed your request and, if appropriate, made care recommendations.

Hair Loss Treatment Survey

Hair Loss Treatment

Choose your Location

What is your date of birth?

Please list the medications you have previously used, as well as the dosage and side effects

When did you first notice hair loss?

Was the hair loss gradual or sudden?

Do you have a family history of hair loss?

Do you have any of these conditions?

Have you had any other problems with the scalp, hair loss (elsewhere on the body), or hair loss after use of prescription medicine

Do you have any of the following health issues?

Are you allergic to any medicines?

Are you currently taking any medicines? Include vitamins, herbs, and over-the-counter products, like pain relievers and sleep aids.

Anything else you would like us to know?

How would you like to pay?

Billing and delivery details

Personal Details

Confirm Request and Agree to Terms

Get in Touch

Al Thiqa Al Dowaliah Pharmacy

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