Hair Loss Treatment Survey

Hair Loss Treatment

There are only a few steps to get started.

    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?

    How quickly did you notice your hair loss?

    Do you have a family history of hair loss?

    Do you have any of these conditions?

    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

    Tell us more about your condition

    Do you have any of the following health issues?

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

    Are you allergic to any medicines?

    Enter medicines

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

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

    Anything else you would like us to know?

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

    How would you like to pay?

    upload emirates insurance details (if available)

    Upload a Photo of your Emirates ID
    Upload Front

    Upload Back

    Billing and delivery details

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

    Personal Details

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

    Confirm Request and Agree to Terms