Please enable JavaScript in your browser to complete this form.Skin Profile - Step 1 of 15Get started creating your hair profile by answering our questionnaire!After filling out the questionnaire, you will receive a complimentary hair loss report with a customized treatment plan and product recommendations! NextWhat stage of hair loss do you have?Androgenetic alopecia is a gradual hair loss process that can happen over the course of many years. The different stages of hair loss can be categorized into the either the Norwood or Savin scale depending on gender. The different stages and patterns of Male Pattern Baldness are seen in the Norwood scale, while Female Pattern Baldness is categorized in the Savin scale.To start, please select your biological gender:MaleFemaleWhich image looks most similar to your pattern of hair loss:Stage 1Stage 2Stage 3Stage 4Stage 5Stage 6Stage 7Stage 8Great! Now please choose the image that is most similar to your pattern of hair loss:Stage 1Stage 2Stage 3Stage 4Stage 5Stage 6Stage 7Frontal PreviousNextIs there any other details you would like to provide about your hair loss? If so, please specify:(ie. is it limited focal patchy type; is it more of a diffuse pattern; is a hair loss all over; is hair loss limited to the top of the scalp, temples, occipital area; is it asymmetrical or symmetrical in appearance)PreviousNextWhich hair loss treatments have you used previously?RogaineMinoxidilPRP InjectionsTransplantsDHT blockersNoneNextAre you experiencing any of the other following symptoms?Itchy scalpOily scalpSevere dandruffPatches of redness on scalp or around hairlinePatches of thick scales on scalp or around hairlineNone Select as many options that apply.PreviousNextHow would you describe the quality of your hair? NormalFine/thinBrittleDryOilyDamaged Select as many options that apply.PreviousNextWhen did you first notice your hair loss?In the last yearIn the last 3 yearsMore than 5 years agoPreviousNextDo you have a history of the following medical issues?High blood pressureBlood clots/vein thrombhosisHigh cholesterolHeart problemsPneumoniaCOVID-19AsthmaDiabetesKidney problemsLiver problemsThyroid problemsAcid reflux/heartburnArthritisRadiation therapyCancerPsoriasisEczemaOtherNoneIf other, please describe the issue below:PreviousNextAre you on a specific diet or dietary restrictions? If so, please specify:PreviousNextAre you taking any medications? If so, please specify:PreviousNextAre you taking any supplements/vitamins? If so, please specify:PreviousNextDid a stressful event occur prior to the onset of hair loss?YesNoIf yes, please briefly describe the event below:PreviousNextHave you been pregnant or suffered a miscarraige within the last 1-2 years?YesNoN/APreviousNextWhat is your age group?Under 1818-2425-3435-4445-5455-6465+PreviousNextLastly, what is your contact information?What is your name? *Email *Which location is nearest to you?203-1447 Ellis Street, Kelowna, BC201-22471 Lougheed Hwy, Maple Ridge, BCUnsureComments (optional)Sign-up to our newsletter?PreviousPhoneSubmit
