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Male Female Other

    1 - Which of the following dandruff symptoms do you have?*

  • Dry scalp
    Flaky scalp
    Itchy scalp
    Oily scalp
    Other
    None of the above

    • 2 - Is there anything in particular that triggers your symptoms?*

  • Stress
    Cold/dry weather
    Other
    No, there isn't anything
    specific that triggers my symptoms

    • 3 - "Do you have these symptoms anywhere else on your body besides the scalp? "*

  • Yes
    No

    • 4 - Have you previously tried any dandruff shampoos, either over-the-counter or by prescription?*

  • Head & Shoulders
    Selsun Blue
    Ciclopirox
    Neutrogena T/Gel
    Clear
    Nizoral
    Others
    No, I haven't tried anything

    • 5 - Was your past treatment effective?


    • Please also list the medication names and how long you used them (or if you are still using them). If you haven't tried any treatments, you can leave this question blank.

    6 - Are you currently breastfeeding, currently pregnant, or may become pregnant?*

  • Yes
    No
    Not Sure

    • 7 - Please list any additional medical conditions, surgeries, or hospitalizations you have had.


    • 8 - Do you take any medicines, vitamins, or supplements?


    • Please list them here.

    9 - Please list any allergies you have.


    • Include any allergies to food, dyes, medications (including prescription medications and over-the-counter medications), insect venom, herbs, vitamins, supplements, and anything else.

    10 - Is there anything else related to the treatment that you'd like to ask or discuss with your medical provider?


    • 11 - Do you have a preferred treatment?*

  • No preference
    Ciclopirox Shampoo|(Generic Ciclodan®)|$35 per month, $39 every 3 months
    Ketoconazole|(Generic Nizoral®)|$35 per month, $60 every 3 months
    • Don't worry if you're not sure. Your doctor will help you pick the best one for you.

    12 - Do you have a preference on how often you'd like your medication?*

  • No preference
    Delivered monthly
    Delivered quarterly

    • 13 - Please enter preferred pharmacy information.*


    • Include a complete information where you would like to pick up your medication.

(Only JPEG, JPG, PNG or PDF format allowed and File size should be less than 10MB)

One Time Consulting Charges: $49.99 (USD)

The above payment is for consultation only and does not cover the cost of your medication. Top Health Center will only send your prescription to your pharmacy of choice.

Disclaimer
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