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Questionnaire for Hair Loss
Are you experiencing hair loss? Required
Do you have hair loss in patches? Required
Are you between 18 and 65? Required
Do you have (redness, inflammation or soreness) in the scalp area? Required
Do you have any known allergies or have any adverse reaction to any medication? Required
Have you been experincing the following?
Could your hair loss be caused by dietary deficiency or any other illness? Required
Do you have a history of depression? Required
Any recent cancer treatment? Required
Are you taking any over the counter medication including recreational drugs? Required
Do you agree with the folllowing statement below? Required

Please contact us if you experienced side effects from the treatment, start new medication or
develop or have a change in your medical condition.


The treatment is solely for you in your own use.


You understand the healthcare provider takes your answers in good faith and base their treatment
on decisions accordingly, and that incorrect information can be hazardous to your health.


You will read the patient information leaflet supply with your medication.


You will notify your primary care physician about your treatment from PBJ medical associates.

Thanks. We'll get back to you soon. Please check your email now for the next steps. 

PBJ Medical RX

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​VISIT

7380 West Sand Lake Road

Orlando, FL 32819

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​CONTACT US

(800) 485-7962
info@pbjmedicalrx.com

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Medical Discliamer - PBJ Medial Associates LLC

© 2025 PBJ Medical RX. All Rights Reserved

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