free shipping on orders over $75 in the us

test-form

    This is to make sure we ask the right questions.
    Date*
    YesNoUnknown
    Have you had any surgery within the last year with General Anesthesia? * YesNo
    Do you have any of the following medical problems? Irregular Heartbeat * YesNo
    Do you take medication to control this condition?
    Coronary Artery Disease:*
    Do you take medication to control this condition?*
    Congestive Heart Failure *
    Depression*
    Stroke*
    Adrenal Hyperplasia *
    Date of last physical *
    Stress Level *
    Have you ever had a scalp biopsy? A scalp biopsy is when a physician removes of a small portion of scalp from the patient’s head which is then sent to a lab for testing. *
    Was a diagnosis made?


    CBC (Complete Blood Count)*
    Hormone: DHEA/Testosterone/Estrogen *
    Thyroid Panel: *
    Glucose: *
    Vitamin D: *
    Was Vitamin D in a normal range? *
    Iron: *
    Was it in a normal range?
    Have you ever been diagnosed with any type of Anemia?








    Overall Thinning I II III III-A III-vertex IV IV-A V V-A VI VII Completely Bald Head
    Overall Thinning 1 2 3 4 5 6 7 8 Completely Bald Head




    Check all that apply.
    We do not agree to work with everyone because not everyone is a good candidate for what we offer. To determine if you are a good candidate, let us know your answer to the following:
    1000
    Write your full name to sign. ATTENTION: Before you submit, please add [email protected] to your contacts and whitelist to prevent your customized report from going into your spam folder.