Hair Pre-Consultation Quiz

What best describes your hair?

Receding hairline

Thinning at the crown

Overall hair loss/thinning

Full head of hair

What sort of results are you looking for?

Regrowing my hair

Preventing future hair loss

Both

Time to get your hair back

Let’s make sure you’re eligible for treatment

My birth date is

What was your biological sex at birth?

For example, on your original birth certificate

Male

Female

Sorry

This offer is not valid for Females

Have you ever been diagnosed with any liver problem?

Yes

Warning

Finasteride requires a healthy liver to be safely metabolized and removed from the body. We are therefore unable to provide you with a prescription at this time. Please speak to your health care provider to see if Finasteride may be safe for you.

I Acknowledge

Have you ever been diagnosed with Breast Cancer?

Yes

Warning

We care about your health here at Rocky. This medication may not be safe for use with breast cancer and we are therefore unable to provide you with a prescription at this time. Please speak to your health care provider to see if Finasteride may be safe for you.

I Acknowledge

Have you ever been diagnosed with prostate cancer?

Yes

Warning

Finasteride can increase the chance of a faster growing or irregular form of prostate cancer. If you have or have had prostate cancer, this drug can make it worse and therefore not safe for use. We are therefore unable to provide you with a prescription at this time.

I Acknowledge

Are you experiencing any of the following symptoms on your scalp?

People can experience various causes of hair loss. We want to know whether yours is one that might be better treated elsewhere.

Burning or pain

Patches of rough, scaly skin or scarring

Pustules or crusting

No, none of these

Warning

This may be the cause of your hair loss and will require direct treatment of the underlying condition. We are therefore unable to provide you with assistance at this time. Please speak to your doctor to determine the care you need.

Do you have any of the following conditions?

Scalp psoriasis

Eczema of the scalp

Ringworm infection

Alopecia areata

None of the above

Is it currently active?

Yes

No, my scalp is clear

Warning

I Acknowledge

Are you currently experiencing any of the following?

Premature ejaculation

Low sex drive

Trouble getting or maintaining erections

None of the above

Have you been diagnosed or currently experiencing any of the following medical conditions ?

Depression

Anxiety

Psychosis

Current or past suicidal ideation

None of the above

Other

Please type your other medical conditions in the box below separated by comma (,)

Warning

We care about your health and want you to be the best version of yourself. If you are currently experiencing suicidal thoughtspsychosis please speak to your doctor immediately or go to your local emergency department.

I Acknowledge

Do you currently take any medications?

Yes

Please enter the exact name and dosing of the medications you are taking

Do you have any other medical conditions?

Certain conditions can complicate diagnosis, increase risks, or change the recommended treatments so it's important for your provider to know.

Yes

Please type your other medical conditions in the box below separated by comma (,)

Do you have any known allergies?

Yes

Please enter the allergies in the box below separated by comma (,)

Photo Upload

Tap to upload Front Hairline photo

The provider needs a photo of your front hairline.

Tap to upload Top of Head photo

The provider needs a photo of the back of your head.

It helps to use a mirror

Only JPEG and PNG images are supported

Max allowed file size per image is 5MB

About your medication

Intended benefits of Finasteride for Hair Loss:

To help prevent further hair loss in male pattern baldness
This is not a cure for male pattern baldness
If medication is stopped, hair loss is likely to start again

When can I expect to see Results:

3 to 6 months

Possible Side Effects:

Erectile dysfunction
Low sex drive
Difficulty ejaculating
Mood disturbance

*Please be aware the above list does not include all possible side effects. If you want to know more, please book an appointment with our healthcare team at the end of this questionnaire.

I have read and understood the intended benefits and possible side effects and do not have any questions

I have questions and will book a phone call

Here’s your first message to your medical provider

Ask any questions you may have about your condition or treatment options (optional)

Would you like to book a call with one of our physicians or pharmacists?

Physician

Pharmacist

Acknowledgement

I hereby acknowledge that by foregoing an appointment with a licensed physician or pharmacist, it is my sole responsibility to ensure I am aware of how to appropriately use the medication requested, furthermore I hereby confirm that I am aware of any potential side effects that may occur through the use of the aforementioned medication and hereby confirm that I do not have any medical questions to ask. I will ensure I have read the relevant product page and FAQ prior to use of the prescribed medication. Should I have any questions to ask, I am aware of how to contact the clinical team at Rocky or get a hold of my primary care provider.

I hereby understand and consent to the above waiver

Please wait while we are loading the recommended hair product...

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