—Please choose an option—Abu DhabiAl AinDubaiSharjahAjman
Less than 6 monthsMore than 6 months
Hair loss was gradualHair loss was sudden
How quickly did you notice your hair loss?
YesNoI’m not sure
Rheumatological disorders including lupus or psoriasisSkin conditions including atopic dermatitis, seborrheic dermatitis, contact dermatitisMajor physical or emotional stressThyroid conditionEating disorderSevere dietary restrictionsNone
Have you had any other problems with the scalp, hair loss (elsewhere on the body), or hair loss after use of prescription medicineItching, 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
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
Are you allergic to any medicines?YesNo
Enter Medicines
YesNo
Enter medicines including names, dose, frequency, and reason for taking.
Tell us about any concerns or questions you have for the medical team.
Out of pocketInsuranceupload emirates insurance details (if available)
Google MapDelivery Location Google Map: (Please Share your Google Map Link) Delivery Location Neighborhood/Area: Street Name/No: Address Details:
Title: Mr.Ms. First Name: Last Name: Date of Birth: Mobile Number: E-mail:
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.
