Men’s Hair Loss

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Email *

First Name *

Last Name *

Phone

Date of Birth *

Check to confirm date of birth *

Check to confirm date of birth

Gender *

Weight *

Height *

Race

Other Race *

Marital Status

Who is the patient? *

What disease are you suffering from? *

Select Your Location *

Let's match you with an authorized medical professional in your state.

Consent to use information *

We kindly request your consent to use the information collected during your interactions with our platform, to ensure transparency and data protection. Visit our privacy policy for more information

Authorization to administer treatment and informed consent *

I thus give my consent for the medical staff at ReddyDoc to examine my medical background and provide telemedicine (synchronous or asynchronous) healthcare to me, the patient.
In the event that my chosen or preferred prescription is possibly hazardous, unsafe, controlled, risky, interacts with another medication I'm taking, or has an adverse drug reaction, I thus give ReddyDoc permission to prescribe an alternate drug.
According to what I've been told, telemedicine services are only appropriate for mild to moderately complex medical requirements. I am aware that ReddyDoc will refuse to treat patients with serious or complex diseases and will cancel their appointments.
I am aware that, in the absence of a physical examination, ReddyDoc will deliver online medical services based on the medical history I submit. I thus accept full responsibility for any injury or losses that may result from providing false, misleading, or incomplete information.
I am aware that using telemedicine has a risk of misdiagnosis because there is no physical exam or in-person evaluation.
I consent to phone 911 or follow up with a doctor for an in-person assessment if my symptoms get worse or don't get better quickly.

I am aware that if my medical practitioner needs more information or if I submit insufficient medical history, the process could be delayed.
I am aware that the consultation charge does not cover the cost of the medicine if I decide to pick up my drug(s) from a pharmacy; I will still be responsible for paying that pharmacy.
I've been told that I can use my insurance to pay for my medication at the drugstore.
I understand that I must email ReddyDoc to request an alternate medication or out-of-pocket (self-pay) options if my insurer is unable to pay for the required test or medication, or if the cost of the medication is prohibitive. I've been told that insurance restrictions or prescription costs are not acceptable justifications for issuing a refund. The patient is financially accountable for their prescriptions and medical services.

Do you have a life-threatening symptom or a medical emergency? *

Yes
No life-threatening symptoms

Unfortunately we do NOT treat life-threatening conditions online. Please call 911

Are you focused and alert? *

You must be focused and aware.

Are you allergic to any medications? *

No, there are no medication allergies (NKDA).
Yes

What drugs do you have an allergy to? *

Are you currently taking any medication? *

Enter medication name *

Medication Disclosure Clause *

I hereby certify that I am NOT currently taking any medication including OTC or supplements, and agree to indemnify and hold ReddyDoc and its employees harmless from any loss, damages, liability, legal liability and expenses resulting from withholding or non-disclosure of my medication or any other vital medical information

Select Relevant Social History

Non-smoker
Drink Coffee multiple times a day
Current smoker (Vape, cigarette or tobacco)
Former cigarette or tobacco use
Prescription drug addiction
Alcohol addiction

Are you the patient in need of medical treatment? *

Yes, I'm the patient in need of treatment
I'm filling out this consultation on behalf of the patient

STOP! PATIENT ALONE MUST COMPLETE THIS FORM

Which of these best describes your pattern of hair loss? *

Thinning hair overtime
Receding hairline
Complete baldness
Rapid hair loss
Sudden onset of hair falling out (typically in small patches)
Bald spots that got bigger over time
Other

Please specify

Select hair loss area *

Scalp
Facial hair
Other area of the body

What other areas of your body are you experiencing hair loss? *

Do you have any of these conditions that cause hair to fall out and prevents new hair from growing? *

Hereditary
Thyroid disorder
Autoimmune condition
Medical treatment such as chemotherapy
Iron deficiency
Vitamin or mineral deficiency
Medication such as isotretinoin, blood thinner, birth control pills
Fungal infection (Tinea Capitis)
Other

Please explain

When did you start noticing significant hair loss? *

Before puberty
Hair loss or balding started less than a year
Over a year ago
Over three years ago
Over five years ago

What is the rate of progression of hair loss? *

Agressive hair loss
Modest hair loss
Mild hair loss

Have you seen a doctor for hair loss? *

Briefly explain your encounter with the doctor *

Have you tried any hair loss treatment? *

Highlight the treatments you've tried *

Do you use any hormonal or nutritional supplements that may contain androgens or testosterone? *

No
I'm on hormonal therapy
I'm on testosterone therapy
I'm taking other steroid or androgens suppleme

What might possibly make your condition worse? *

Describe what could help your condition *

Do you have a family history of hair loss (hereditary hair loss)? *

Yes
No family history of hair loss

Which of these medications would you like us to prescribe?

Finasteride tablet (Recommended)
Topical minoxidil solution
I'll let the doctor decide

Select Preferred Rx Plan *

($39.99) BASIC: online visit (30 day supply sent to your PHARMACY with NO REFILLS) NOTE* medication NOT included, you still need to pay for your Rx at the PHARMACY
($49.99) ADVANCED: online visit (30 day supply sent to your PHARMACY with 2 REFILLS) NOTE* medication NOT included, you still need to pay for your Rx at the PHARMACY
($60) QUARTERLY SUBSCRIPTION PLAN *BEST VALUE: online visit (90 day supply. Delivered directly to you automatically every 90 days until cancelled)

Important Information: We do not include the cost of medications in the consultation price. *

I am aware that even if my insurance does not cover a particular prescription, I will still need to pay for it at my local pharmacy.

Follow-up agreement *

I understand and agree to follow up with a doctor in-person or go to the ER immediately if the patient's symptoms persist or worsen

On the next screen, kindly upload at least two distinct pictures of the body part. incorporate the places *

On the next screen, I'll post images of the impacted area.
I sent images to ReddyDoc via email at (provider@www.condition.reddydoc.com)
Pictures have been texted to ReddyDoc at +1 (888) 512-9213

Upload any medical records, test results, pathology reports, or photographs that are clinically relevant.

File Upload

Click or drag files to this area to upload. You can upload up to 3 files.

Given the limitation of telemedicine, we encourage an in-person follow-up if your medical concerns do not resolve after a telemedicine visit. *

I agree to follow-up for an in-person re-evaluation with a local doctor as needed
I have an upcoming appointment with my doctor

When is your next doctor's appointment? *

Leave a comment or feedback (Optional)

Supplemental Service Disclosure *

We prescribe FDA-approved medications and follow evidence based medical guidelines. In some cases, the initial medication may not completely eradicate your symptoms or cure the infection. In this situation, similar to other clinics and doctor's offices, the patient is responsible to pay for the follow-up visit and repeat treatment.
I have been informed that it's my responsibility to handle prescription medication with care and store it in a safe environment. There's an additional fee to reissue lost or misplaced medications.
I understand that there is a processing charge of $20 when a request is made for an excuse note or doctor's letter
I understand that there's a $50 surcharge when a request for prior authorization or peer to peer review is required by your insurance or payer

Refund Policy Terms *

I am aware that I have a full refund option at any point before ReddyDoc sends my prescription. Our consultation charge is no longer refundable once a medical professional has finished your treatment plan, submitted your prescription to your pharmacy, requested a test, or fulfilled your request.
We aim to finish every consultation in under two hours. However, insufficient medical data, technical issues, or a high patient load may cause the turnaround time to be prolonged. Be prompt if you must cancel due to delays. If your request for a refund is made after we have sent your prescription to the pharmacy or finished the treatment plan, the consultation fee is NOT refundable.
I am aware that the consultation cost is non-refundable in the event that my body does not respond to therapy or if the prescribed medicine does not entirely cure my disease or eliminate all of my symptoms. You are welcome to submit a second consultation for review.

Would you wish to offer a Power of Attorney or an Emergency Contact? *

Yes, I want to add a power of attorney or an emergency contact.
No! Please under no circumstances disclose my medical information to my relatives or friends.

Enter the Full Name and Birthdate of the Emergency Contact (IMPORTANT). *

Do you want to give the person who handles emergencies access to your medical records? *

Yes! I hereby authorize ReddyDoc and its staff to provide my emergency contact with access to my medical records.
No! I DO NOT authorize anyone to access my medical record or act on your behalf other than ReddyDoc, its designated agents, and employees.

Enter the Full Name and Birthdate of the Emergency Contact (IMPORTANT). *

Pharmacy Name *

Pharmacy Address *

Pharmacy Phone *

Billing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Consultation fee

Price: $34.99

Stripe Credit Card *