Hair Matrix Consult Form - Hair Loss Clinic Birmingham

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- Hair Matrix Consult Form
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Suitability Check

We just need to check if this plan is suitable for you. Please answer the following questions accurately:

1 What was your sex assigned at birth?

Male Female

⚠️ We’re sorry, but this treatment may not be suitable based on your response. If your response is incorrect, please answer accurately.

2 Do you have a history of hair loss in your family?

Yes No

3 Are you experiencing any of the following?

None of these apply Sudden, intense hair loss (within 6 weeks) Scalp inflammation or burning Hair loss in patches

⚠️ We’re sorry, but this treatment may not be suitable based on your response. If your response is incorrect, please answer accurately.

4 Could medications or illness be causing your hair loss?

Yes No

⚠️ We’re sorry, but this treatment may not be suitable based on your response. If your response is incorrect, please answer accurately.

5 Are you allergic to any of these?

No allergy Allergic to Finasteride Allergic to Minoxidil Allergic to Tretinoin

⚠️ We’re sorry, but this treatment may not be suitable based on your response. If your response is incorrect, please answer accurately.

6 Are you taking any of the following medications?

None Medicines for prostate issues Corticosteroids High blood pressure meds

⚠️ We’re sorry, but this treatment may not be suitable based on your response. If your response is incorrect, please answer accurately.

7 Have you ever been diagnosed with any of the following?

None Depression or other mental illness Heart disease High blood pressure Kidney/liver disease Male breast cancer Scalp infections Psoriasis or dermatitis on scalp

⚠️ We’re sorry, but this treatment may not be suitable based on your response. If your response is incorrect, please answer accurately.

8 Do you consent to us contacting your GP?

Yes No

9 Ready to move forward?

I understand these personalized medications have been prescribed to meet my unique needs by a licensed professional.

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