Full Name Required

Name in Japanese Katakana

Email Address Required

Date of Birth Required

Sex
MaleFemalePrefer not to say

Mobile Phone Number Required

Address Required

Occupation

First or Returning Visit Required

First visitReturning visit

Preferred Visit Date Required

Preferred Visit Time Required
Please select a time11:0011:3012:0012:3013:0013:3014:0014:3015:0015:3016:0016:3017:0017:3018:0018:30

Reason for Consultation Required

EDAGA / Hair lossED and AGAOther

Questions or Additional Information

Treatment Category
EDAGA / Hair lossED and AGAOther

Other Medication Requests or Questions

Height Required


cm

Weight Required


kg

Do You Have Any Allergies? Required

NoYes

Allergy Details

Do You Have Any Current or Previous Medical Conditions?
Required

NoYes

Medical Condition Details

Are You Currently Taking Any Medication?
Required

NoYes

Current Medication Details

Have You Ever Had a Major Illness or Surgery?
Required

NoYes

Major Illness or Surgery Details

Other Health Information

Have you been prescribed nitroglycerin or any nitrate medication
for a heart condition? Required

NoYes

Do you have a serious heart condition, vascular condition,
or severe liver impairment? Required

NoYes

Have you had a stroke, cerebral hemorrhage,
or myocardial infarction within the past six months?
Required

NoYes

Have You Used ED Medication Before?
Required

NoYes

Have You Used AGA or Hair-Loss Medication Before?
Required

NoYes

Have You Been Diagnosed With Retinitis Pigmentosa?
Required

NoYes

Blood Pressure Status Required

Low blood pressureHigh blood pressureNormalUnknown