Hair Loss Assessment

Step 1 of 6

Your details

Please provide your legal details so our prescribing team can review your request safely.

Legal first name Legal last name

Email address

Phone number Date of birth

Sex assigned at birth

Your hair loss and scalp

These questions help us understand the likely pattern of hair loss and identify symptoms that may need a different assessment.

When did you first notice hair loss? How did it begin?

Which pattern best describes your hair loss? Please describe the pattern

How has it changed? Does hair loss run in your family?

Do any of the following apply?

Patchy hair loss Rapid or heavy shedding Scalp pain, burning or tenderness Redness, scaling or significant flaking Pustules, crusting or discharge Smooth, shiny or scarred-looking scalp Eyebrow, eyelash, beard or body hair loss Mainly hair breakage rather than shedding None of these

Please provide more detail Has a healthcare professional diagnosed your hair loss? What diagnosis were you given?

Your details

Delivery address

Your hair loss and scalp

Current and previous treatments

Medical and safety screening

Photos and confirmation