Capillus Laser Cap - FDA Cleared for Men's and Woman's Hair Loss- Oline Physician Evaluation

Capillus® Laser Cap - Hair Loss Evaluation Form

Capillus Online Hair Evaluation - Buy Capillus NOW

Begin your journey toward a natural, thicker, more youthful head of hair. Complete the form below and a Medical Wellness Center physician will confidentially review your answers to determine if low level laser therapy is suitable for you.. Your privacy and security are our top priorities. For more information.

Newly Approved Capillus®202 Laser Cap - only $1999
Capillus®82 - Retail price $799
Capillus®272 - Retail price $2999

Please Choose Capillus®82 Laser Cap or Capillus®272 Laser Cap:

FDA cleared Capillus®82: for only $799
Introducing the newest FDA cleared Capillus®202: for only $1999
Capillus®272 : Retail price $2999

Please answer the questions below for our physicians to evaluate if you are a candidate for hair loss therapy

Click here to read the stated conditions before filling out the medical consultation form: I have read the previous Capillus® pages and I understand that this evaluation is only to determine if I am a candidate for Capillus® LLLT device and does not diagnose underlying medical conditions. I understand that I need to visit my primary care physician for medical conditions:YES ]NO

The medical information you supply is subject to ALL patient/doctor privilege laws.

**MEDICAL HISTORY**
First and Last Name: Do you have a prescription from Medical Wellness Center for Propecia or Avodart, topical minoxidil or Latisse?YESNO If yes, enter Medical Wellness Center Membership Number: SEX: Female Male Date of Birth(MM/DD/YY): Current Age: Height (inches):Weight:


Please list all current Medical Conditions: Do you take any prescription medication?YESNO If YES, please list all Prescription Medications you are currently taking and the length of time taking each of them: For example: Claritin -4yrs; Zoloft- 6mo,etc. Please list all over-the-counter drugs you take regularly and why. For example: aspirin -for migraines, Unisom -difficulty sleeping etc. Have you had a physical exam in the last two years?YES NO


Do you suffer from finer or thinning hair?YESNO
Do you suffer from Male Pattern Hair loss?YESNO
Have you found more hair than usual on your pillow, brush or shower drain? YES NO
In the part down the middle of your scalp, does the width of the part show more scalp than normal? YES NO
MEN: Are you experiencing SUDDEN hair loss unrelated to male pattern hair loss? YES NO WOMEN: Are you experiencing SUDDEN hair loss rather than gradual menopausal age related hair thinning? YES NO
Is your hair loss due to the side effect of medication or chemotherapy or nutritional disease or thyroid disease? YES NO
Is your hair loss due to chemical treatment of your hair - perms? relaxing? coloring? or from hairstyle such as cornrowing? ponytail?YESNO
Are you using any other medicines on your scalp?YES NO If yes, please explain:
Do you have any skin conditions on your scalp such as eczema, psoriasis, red inflamed painful scalp conditions?YESNO If yes, please explain:
Are you currently being treated for cancer?YES NO If yes, please explain:


Do you consider anything in your medical history to be relevant, please give details. If unsure, please ask your regular doctor


FAMILY HISTORY:
Does Male Pattern Hair Loss run in your family?YES NO Have any members of your immediate or extended family, male or female, experienced hair loss?YES NO
Are there any other diseases than run in your family?

**HAIR LOSS HISTORY**
Have you sought professional advice for your hair loss?YESNO
If yes, please explain:
Do you suffer from Male Pattern Baldness?Yes No
Have you been treated before for hair loss?Yes No
Check each treatment that you have undergone:minoxidil Propecia (finasteride)Avodart (dutasteride)LatisseSurgicalLight Therapy Other
If other, please list other treatments for hair loss
Are you currently being treated for hair loss?Less than 6 months 6 months to 1 year 1 to 5 years More than 5 years If Yes, Please describe your current hair loss treatment regimen:
At what age did you first notice hair thinning?
Was your hair loss Sudden not due to Male Pattern Hair loss or Gradual Is your hair loss due to the side effect of medication or chemotherapy or nutritional disease or thyroid disease? YES NO Is your hair loss due to chemical treatment of your hair - perms? relaxing? coloring? or from hairstyle such as cornrowing? ponytail?YESNO
Please describe your history of hair loss:



MEN: from the illustration and description below, choose which Norwood Classification of Hair Loss best describes your present condition: please select your current Norwood Classification: Class 2: Receding Hairline Class 3: Generalized Frontal Thinning Class 4: Frontal Area & Crown Balding Class 5: Top of Scalp & Crown Balding Class 6: Extensive Hair Loss Class 7: Severe Hair Loss Only rim of hair remains
WOMEN: Please from the illustration and description below, choose which Classification of Hair Loss best describes your present condition: Women please select your current Norwood Classification: Type I Type II Type III Type IV Type V

**PERSONAL and PAYMENT INFORMATION**
In order to review your consultation, you must provide your full name, a Physical Address (We do NOT accept requests to PO Boxes) and complete Phone number. If you live outside of the United States, we will first have to confirm with Capillus® *Manufacturer that they can ship to your country*
FULL NAME:
SHIPPING ADDRESS: (Physical Address Necessary We do NOT process any orders to PO BOX#'s)
CITY:
STATE:	ZIP CODE
COUNTRY:
PHONE (REQUIRED):
EMAIL: (REQUIRED)
Please provide complete email, ie You@domain.com or name@aol.com
NAME OF CREDIT CARD HOLDER
ENTER CREDIT CARD TYPE:
ENTER CREDIT CARD NUMBER
BILLING ADDRESS:
BILLING ZIP CODE
EXPIRATION DATE(MM/YY):

I, AS THE CREDIT CARD HOLDER, VERIFY THAT I AM SUBMITTING THIS ONLINE-CONSULTATION REQUEST FOR A MEDICAL PRESCRIPTION to PURCHASE A Capillus® LLLT DEVICE. I AUTHORIZE THE CHARGES STATED TO BE MADE TO MY CREDIT CARD (I understand that if I later dispute this charge as "unauthorized" I will be subject to criminal prosecution for credit card fraud). If credit card holder name is different than the person submitting consultation, you must verify that you have been given authorization to use this credit card: I VERIFY THAT I HAVE BEEN GIVEN AUTHORIZATION BY CREDIT CARD HOLDER TO USE ABOVE CREDIT CARD.( I understand that if this charge is disputed by credit card holder as unauthorized, I will be subject to penalties of criminal prosecution for credit card fraud.)YES NO


By submitting this consultation form, I certify:
I am 18 years of age or older. I have read and understand that no promises or guarantees can be made to an individual's response Capillus® LLLT I understand that their are currently no reported side effects to the Capillus® device when used correctly. I understand that I need to continue regular visits to my primary care physician to diagnose any possible underlying medical conditions. I understand that my credit card will be billed $799 + $50 shipping & handling if I choose FDA -Cleared Capillus®82 Laser cap. If I choose the newest FDA-cleared Capillus202® laser cap my card will be billed $1999 + $50. If I choose Capillus272®LLLT device I understand the retail price is $2999 + $50 shipping & handling. I understand my credit card will be billed either $849 for the Capillus82, or $2049 for Capillus202, or $3,049 for the Capillus272 if approved. There is no charge for the consultation. Capillus® manufacturer directly provides you with a 3 year warranty, and any issue with Capillus cap is serviced directly from Capillus. I understand that by submitting this form it's an "electronic signature" of a binding agreement that I agree to pay the $799 for the Capillus®82 or $3000 For the Capillus®272 if approved. I understand that there are no refunds for any circumstances. Once your receive your Capillus®device, you will deal directly with the manufacturer regarding any and all issues and warranty issues. Please Confirm your choice of Capillus®82 Laser Cap or Capillus®272 Laser Cap: Capillus®82: for only $799 +$50 processing Capillus®202: for only $1999 +$50 processing Capillus®272: Retail price $2999+ $50 processing

Click SUBMIT button for Physician Consultation and to Purchase the CAPILLUS® LLLT device

You may submit Consultation Form over the Internet (secure server) by clicking the SUBMIT button.


PHONE NUMBER: (US ONLY)	617-367-8887
Medical Wellness Center Boston, MA

To contact Medical Wellness Center - Hair-loss treatment for Men with any questions, please Email us.

N=RIGHT COLSPAN="2" ROWSPAN="3"> Medical Wellness Center
Boston, MA

To contact Medical Wellness Center - Hair-loss treatment for Men with any questions, please Email us.