Let’s Get to the Root of Your Hair Concerns What is your email? Are you currently an active patient in Ness’ weight loss program? NoYes Would you like to bundle your hair loss medication with your medical weight loss prescription? NoYes How satisfied are you with your hair overall? Not at allA little bitSomewhatQuite a bitVery What is your goal for hair loss treatment? I want to prevent further hair lossI want to regrow hairI want fuller, thicker-looking hairI have a full head of hair I’d like to maintain Where are you noticing hair loss or thinning? Both hairline and crownReceding hairline (along my forehead or temples)Thinning crown (top of my head)Overall thinningRandom golf-ball size bald patches scattered all over scalpNowhere yet, but I’d like to prevent future hair loss Have you ever treated your hair loss with medication? NoYes What treatments did you receive? Oral MinoxidilTopical Minoxidil or RogaineOral Finasteride or PropeciaTopical FinasterideSteroid injections in the scalpOther Please tell us more about your treatment experience (effectiveness, side effects, etc.) Have you noticed any of the following? None of these Redness or rashes on scalp Pain Soreness Burning, and/or tingling in areas of hair loss Recurrent pus bumps or open sores on scalp Partial or complete loss of eyebrows or eyelashes Loss of body hair Have you ever been diagnosed with or treated for high or low blood pressure? NoYes, I have been diagnosed or treated for high blood pressureYes, I have been diagnosed or treated for low blood pressureI’m not sure Do you have, or have you ever had, any of the following conditions? None of these Heart failure Pericarditis Benigin prostatic hyperplasia Repeated chester pain or tightness, also called angina Arrhythmia or abnormal heart rhythm Coronary artery disease, or narrowing of the heart vessels Coronary bypass surgery Heart attack Stroke Pheochromocytoma (adrenal gland tumor) Pulmonary hypertension Prostate cancer Kidney disease Erectile Dysfunction Anxiety Depression Eczema Please list any prescription medications, over-the-dounter medications, vitamins, dietary supplements, and topical creams you are currently taking or using, including dosages. Please type N/A if none. Are you allergic to any of the following? Please select all that apply. None of these Finasteride (oral or topical) Minoxidil (oral or topical) Ketoconazole (oral or topical) Latanoprost Please list all of your known allergies. Please type N/A if none. Basic Information First Name Last Name Date of Birth Sex at Birth FemaleMale Phone Please upload a government-issued form of ID (Driver’s License, Passport, etc.). Please be sure that your full name and photo are easily visible. What type of consultation would you prefer? Email and Text Message (Fastest Option)VideoPhone Call How did you find Ness? Please attest to the following confirming that all the information you provided is true and complete. If you do not agree, you may not submit this form. I confirm that I am the patient completing this intake form and have reviewed all questions carefully. I attest that my answers are true, accurate, and complete to the best of my knowledge. I understand the importance of providing my doctor with complete and accurate health information for my care. I agree and consent Ness doctors review every form within 24 hours. Do you have any further information which you would like the doctor to know? Payment Information We'll securely collect your payment information now, but you won't be charged until your intake form has been reviewed. If you qualify for medical weight loss, your first month’s prescription will be billed at that time. If you're not eligible, a $30 non-refundable evaluation fee will be charged to cover the cost of the medical review. Card Number Expiration Date (MM/YY) Security Code Name on Card Referral Code (if applicable) Shipping Address Address Apartment, Suite, etc. (Optional) City State Zip Code Is your shipping address the same as billing? YesNo Billing Address Address Apartment, Suite, etc. (Optional) City State Zip Code
