Dr. Ayyaz M. Shah / Dr. S. Michael Fuhrman / Dr. Michael Albert / Dr. Sheila Calderon


For more customized treatment options, please complete the form below and a certified hair loss professional will contact you. HLCC® home treatment options were designed for those too far from a treatment center and when customized to each individuals specific hair loss needs, have proven very effective, convenient and affordable.

Personal Details

  • Male  Female
  • Slightly    Moderately    Highly

  • Prevent further loss   Quickly regain some hair   Gradually regain a lot of hair   Other:

Medical History

  • Yes    No

  • Stroke Congestive Heart Failure
    Irregular Heart Beat Hypertension/Hypotension
    Coronary Artery Disease Anemia
    Depression Thyroid Disease
    Hormone Inbalance Liver Disease
    Rosacea Polycystic Ovarian Syndrome
    Lactose Allergy

  • CBC w/Diff Ferritin/Iron test
    Thyroid Panel Glucose Tolerance
    Hormone: DHEA Hormone: Testosterone
  • Please list any current medications and/or supplements with dosage:

  • Radiation Therapy: Yes    No
    Chemotherapy: Yes    No

  • Yes    No


  • High     Medium     Low
  • Yes    No

Hair Care Routine

  • Yes    No


  • Dry    Oily   Normal    Dandruff
  • Yes    No
  • Yes    No
  • Yes    No


  • Yes    No
  • How many daily servings do you get of:

  • Yes    No

Hair Loss

  • Yes    No
  • Caucasian    Ethnic    Other:


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