Name* First NameLast Name Email* ejemplo@ejemplo.com Phone Number* Date of Birth* -Month -DayYear Where do you live?* Select AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Current Date (hidden) -Month -DayYearDate Age Calculation (hidden) We're sorry, we offer out services to people aged 18-65 and we're not yet in CA or NJ. Back Next From a cultural standpoint, how do you identify? Hispanic, Latino or Spanish originAmerican Indian or Alaskan NativeAsian / Pacific IslanderBlack or African AmericanWhite / Caucasian What language do you speak?* I speak mostly EnglishI speak mostly SpanishI am comfortable with either What gender do you identify with?* WomanManNon-Binary What is your assigned biological sex at birth?* FemaleMaleIntersex Do you have any history of gender affirming surgery (ie. bottom surgery)?* YesNo Are you currently pregnant or breastfeeding, or did you give birth recently, less than 6 weeks ago?* YesNo gender calc (hidden) We're sorry! We cannot offer our treatments to you at this time if you have a history of gender affirming surgery or if you're currently pregnant or gave birth less than 6 weeks ago. We suggest you consult your doctor for this treatment. Back Next Do any of the following apply to you?* History of Congestive Heart Failure (CHF)Undiagnosed scalp rashes/lesionsNone of the above Before we can prescribe medications for hair loss, we need to know if any of these conditions apply to you* One or more of the conditions listed below apply to meNone apply to me - Depression or anxiety - Actively trying to conceive - History of decreased urinary flow - History of prostate cancer - Liver disease - Undiagnosed rashes/lesions on the scalp Given your response to the last question, we suggest that you consult your doctor for this treatment Back Next Last question! How did you hear about Cora?* InstagramFacebookFriends and familyGoogleEmailOther MailChimp Tags See plans Should be Empty:
