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—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
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?
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
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?
Enter medicines including names, dose, frequency, and reason for taking.
Reason for Taking:
Tell us about any concerns or questions you have for the medical team.
Out of pocketInsuranceupload emirates insurance details (if available)
Upload a Photo of your Emirates ID
Google MapDelivery Location Google Map: (Please Share your Google Map Link)
First Name: Last Name:
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.