Begin Declaration

Health Declaration

Alopexia is a prescription medicine. Based on the results of your health declaration, our medical team will determine if Alopexia is suitable for you. If appropriate, a licensed doctor will provide a prescription, and your treatment will be specially formulated to address your hair concerns. By proceeding, you confirm that you understand Alopexia is a prescription product and that a medical evaluation is required before purchase. The information provided is confidential and only seen by authorized doctors.

Health Declaration

Your Mobile Number

Please select your Birth year

How long have you been experiencing hair loss?

Are you currently undergoing any treatment for hair loss?

Are you currently taking any of the following medications: Advodart, Combodart, Duodart, Jalyn, Dutasteride, Proscar, Propecia, Finasteride?

Do you experience symptoms of depression or are you currently taking antidepressants?

Do you have any medication allergies?

Have you ever had or do you currently have any of the following conditions?

Have you ever had or do you currently have any of the following scalp conditions?

Please check the boxes to confirm your commitment:

Please select your Birth year

Do you have a family history of hair loss?

Have you recently applied any hair products such as thickening sprays, keratin treatments, or styling agents to your hair?

Have you reached menopause or are you currently experiencing menopausal symptoms?

Are you currently undergoing any hormone therapy, such as estrogen treatment, for menopausal symptoms?

Are you currently taking any medicines?

Do you have any known allergies?

Have you recently undergone a major illness, surgery, or weight loss?

Do you have a personal or family history of breast cancer?

Have you tried any hair loss treatments?

Do you have any allergies to the following substances?

Please check the boxes to confirm your commitment:

Country/region

Language

Health Declaration

You're Eligible for a Prescription!

Your Mobile Number

Please select your Birth year

How long have you been experiencing hair loss?

Are you currently undergoing any treatment for hair loss?

Are you currently taking any of the following medications: Advodart, Combodart, Duodart, Jalyn, Dutasteride, Proscar, Propecia, Finasteride?

Do you experience symptoms of depression or are you currently taking antidepressants?

Do you have any medication allergies?

Have you ever had or do you currently have any of the following conditions?

Have you ever had or do you currently have any of the following scalp conditions?

Please check the boxes to confirm your commitment:

Please select your Birth year

Do you have a family history of hair loss?

Have you recently applied any hair products such as thickening sprays, keratin treatments, or styling agents to your hair?

Have you reached menopause or are you currently experiencing menopausal symptoms?

Are you currently undergoing any hormone therapy, such as estrogen treatment, for menopausal symptoms?

Are you currently taking any medicines?

Do you have any known allergies?

Have you recently undergone a major illness, surgery, or weight loss?

Do you have a personal or family history of breast cancer?

Have you tried any hair loss treatments?

Do you have any allergies to the following substances?

Please check the boxes to confirm your commitment: