Answer a short questionnaire and a licensed health provider will assess your condition within 24 hours. Your progress is automatically saved.
You will be required to upload the following. Please have them ready or prepare to take photos for faster completion:
- Government ID
- Provincial health card
- Private insurance card (if any)
- Photos of your frontal hairline and crown
- Selfie for identification purposes
By proceeding, you agree that you:
- Are biologically male at birth
- agree to our privacy policy and terms and conditions.
- Are completing this form for yourself and will answer the questions accurately and completely to your best ability
- Will disclose and consent to have stored the information of any prescription medication you currently take and any serious illnesses or surgeries you have had.
- Understand that hair loss medication is a last resort treatment for when alternative means have proven ineffective. Hair loss is best addressed with preventative and management treatments such as using gentle hair products, protecting your hair from excess heat and sunlight, and smoking cessation. Alopecia may also be caused by pre-existing conditions and certain cancer medications. By proceeding with the intake form, you accept any risks involved in the consultation, diagnosis and treatment regime for any contributing conditions and in the treatment we prescribe. We strongly recommend you have your primary care provider assess you for the possibility of pre-existing conditions prior to using our service.