This helps your physician understand your background before reviewing your case.
Please enter your first name
Please enter your last name
Please enter a valid age (18+)
Please select your state
Please enter a valid email address
Hair loss profile
Tell us about your hair loss
Be as honest as you can — this directly shapes your treatment plan.
How long have you been experiencing hair loss?
Less than 3 months
Recent onset, may be acute shedding
3–6 months
Subacute — pattern beginning to form
6–12 months
Established pattern emerging
1–3 years
Chronic, progressive loss
Over 3 years
Long-standing, may have tried treatments
Where are you noticing loss? (select all that apply)
Crown / top of head
Temples / hairline
Widening part
All over / diffuse
Patches
Thinner ponytail
How severe would you rate your hair loss?
1
2
3
4
5
Mild thinningSignificant loss
Medical history
Your health background
Hair loss is often connected to hormonal, thyroid, or nutritional factors. This helps your physician identify the root cause.
Which of these apply to you? (select all)
Postpartum (within 12mo)
Perimenopause / menopause
Thyroid condition
PCOS
Iron deficiency / anemia
High stress period
Significant weight loss
None of these
Are you currently taking any medications?
No medications
Yes — I'll list them
Have you tried any hair loss treatments before?
Minoxidil (Rogaine)
Biotin / supplements
PRP injections
Laser therapy
Prescription shampoos
None yet
Photo upload
Help your physician see what you see
Photos are the single most important factor in an accurate remote diagnosis. Your physician needs to see the pattern, not just read a description.
📷 Photo guidance
Take in good natural light — no flash
Top-down view showing the crown and part line
Front hairline photo (pulled back if needed)
Side view showing temples
Hair pulled into a ponytail to show thickness
☁
Tap to upload photos
JPEG or PNG · Up to 10MB each · 2–4 photos recommended
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Your photos are private. They are encrypted in transit and at rest, stored on HIPAA-compliant servers, and only visible to your assigned physician. They are never shared, sold, or used for marketing.
Your goals
What matters most to you?
This helps your physician understand what success looks like for you — not just clinically, but personally.
My primary goal is to…
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Stop the shedding
Halt ongoing loss before it progresses further
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Regrow lost hair
Restore density where I've already lost it
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Both — stop loss and regrow
Comprehensive treatment addressing all aspects
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Understand the cause first
I want a proper diagnosis before committing to treatment
How is hair loss affecting you emotionally? (be honest — this matters)
1
2
3
4
5
Barely affects meDeeply distressing
Review
Almost there — review your answers
Check everything looks right before we send your case to a physician.
About you
Name—
Age—
State—
Email—
Hair loss profile
Duration—
Location—
Severity—
Medical history
Conditions—
MedicationsNone
Prior treatments—
Goals
Primary goal—
Emotional impact—
Photos uploaded0
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HIPAA-compliant & private. Your information is encrypted and shared only with your assigned Florova physician. We never sell or share your data.
I consent to Florova sharing this information with a licensed physician for the purpose of evaluation and treatment. I have read and agree to the Terms of Service and Privacy Policy.
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Your assessment is submitted
A licensed dermatologist will review your case and send you a personalized treatment plan within 24–48 hours.