Form - Finasteride – DIMA Health Technology Inc.

You're just a few questions away from regrowing your hair!

Please fill this questionnaire to complete your order.

Please enter your first name:

Please enter your last name:

Please enter your email:

What was your sex assigned at birth?

Male

Female

How old are you?

Where are you noticing hair loss or thinning?

Receding hairline (along my forehead or temples)

Thinning crown (top of my head)

Both hairline and crown

Random, patchy hair loss scattered all over my scalp

Nowhere yet, but I'd like to prevent future hair loss

How would you rate your hair loss?

Mild

Moderate

Severe

Extremely Severe

What was your latest blood pressure reading in the last 6 months?

If you have 'Very High' or 'Low' blood pressure, it might not be safe to take Sildenafil.

Low

Normal

High

Very High

Have you taken any hairloss medications before?

Yes, Finasteride or Propecia

Yes, Minoxidil

Not Yet

Please select any that apply to you:

If you have any medical condition not listed previously, please list them below.

If you have had any surgeries or hospitalizations please list them below.

If you are taking any medications please add them below.

If you have any allergies to medications, please list them below.

Thank you for filling the form!

You can now select products you want to add to your cart: