Script Request

Medical Hair Restoration sml

Submitting this form does not guarantee that a prescription will be issued. A Medical Hair Restoration doctor will review your information and determine suitability based on your clinical profile.

    Are you male or female?
    MaleFemale

    Are you pregnant, trying to become pregnant or breast feeding?
    YesNo

    Do you have a history of heart disease?
    YesNo

    Are you allergic to any medication?
    YesNo

    Are you taking blood pressure medication?
    YesNo

    Do you have any significant medical history (any medical or surgical conditions that we should know about)?
    YesNo

    9 Somerset Road, de Waterkant Center, Green Point, Cape Town, 8000

    Phone: +27 21 425 77 55

    Web: www.medhairdrjankelowitz.co.za