Hair Loss Intake Form

What is your email?*

Are you currently an active patient in Ness’ weight loss program?*

Yes

Would you like to bundle your hair loss medication with your medical weight loss prescription?*

We highly recommend bundling with our medical weight loss program, as you can save up to 45% off your medication.

Yes

Which GLP-1 are you currently taking, as prescribed by Ness?*

How satisfied are you with your hair overall?*

Not at all

A little bit

Somewhat

Quite a bit

Very

What are your top priority goals for hair loss treatment?*

I want to prevent further hair loss

I want to regrow hair

I want fuller, thicker-looking hair

I have a full head of hair I’d like to maintain

Where are you noticing hair loss or thinning?*

Have you ever treated your hair loss with medication?*

Yes

What treatments did you receive?*

Oral Minoxidil

Topical Minoxidil or Rogaine

Oral Finasteride or Propecia

Topical Finasteride

Steroid injections in the scalp

Other

Please tell us more about your treatment experience (effectiveness, side effects, etc.)*

Have you noticed any of the following? (Please check off all that apply)*

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?*

Yes, I have been diagnosed or treated for high blood pressure

Yes, I have been diagnosed or treated for low blood pressure

I’m not sure

Do you have, or have you ever had, any of the following conditions? (Please check off all that apply)*

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

Liver 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)*

Finasteride (oral or topical)

Minoxidil (oral or topical)

Ketoconazole (oral or topical)

Latanoprost

None of the above

Please list all of your known allergies. Please type N/A if none.*

Tell Us About Yourself

Name*

First Last

Phone Number*

Date of Birth*

MM slash DD slash YYYY

Sex at Birth*

Female

Male

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.*

Max. file size: 5 MB.

What type of consultation would you prefer?*

Email and Text Message (Fastest Option)

Video

Phone Call

Expected Timelines: Email & Text - intake reviewed within 48 hours | Video or Phone - approval may take 5-7 days

How did you find Ness?*

Consent*

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?

One Last Step

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.

Promo Codes

Shipping Address*

Street Address Address Line 2 City State ZIP Code

Is your shipping address the same as billing?*

Yes

Billing Address

Street Address Address Line 2 City State ZIP Code

Use code YESNESS at checkout for a discounted first month!

Let’s Get to the Root of Your Hair Concerns

Tell Us About Yourself

One Last Step

Need Anything?