Demo Intake — Hair Loss | Evolve Health (Preview)

Step 1 of 13 — Eligibility gates

A few quick checks to make sure this online program fits you.

Are you having any urgent symptom listed above right now? * No Yes

I confirm each of the following (all must apply): * I am 18 years of age or older. I am physically located in Texas during this evaluation. I am a man seeking care for pattern hair loss. I understand this is not emergency care. I understand a Clinician will review my answers and treatment is not guaranteed.

Your date of birth *

Step 2 of 13 — About you

Basic contact details so we can reach you about this care.

Legal first and last name *

Street address *

City *

State *

ZIP code *

Mobile phone *

Email *

How may we contact you about this care? * Phone call Text message Secure portal message

May we leave a generic voicemail (no medical details)? * Yes No

Step 3 of 13 — Identity verification

Required before Clinician review.

Before a Clinician can prescribe, we verify identity — this protects you and keeps online care safe. Upload a clear photo of your government-issued ID (driver license, state ID, or passport) and a selfie. The name and date of birth on the ID must match this form. Your ID and selfie are stored only in your secure chart. Your ID and selfie are stored only in your secure chart.

If your ID cannot be verified, or your selfie does not match your ID, your care is pickup-only at a pharmacy if the Clinician approves treatment, and the Clinician may require a video visit first.

Photo of the FRONT of your government ID *

Use whichever is easier — Take a photo opens your camera right here, or upload a photo you already have.

Take a photo

Demo only — files are never uploaded.

Upload a photo

Photo of the BACK of your ID — the barcode side *

The barcode on the back must match the front of your ID. This is how we confirm the ID is genuine.

Take a photo

Upload a photo

Selfie *

Look at the camera like a passport photo — no sunglasses or hat.

Take a photo

Upload a photo

The name and date of birth on my ID match the information on this form. *

The payment card you enter at checkout must be in your own name and match your ID.

Step 4 of 13 — Your concern and goals

Tell us what you would like help with.

What would you like help with? Check all that apply. * Receding hairline Thinning at the crown (top/back of the head) General thinning across the top of the scalp Slowing further hair loss Regrowing hair where I have thinned Refill or continue treatment I already use Discuss which option fits me best Other

Your main goal for this visit (optional)

Which treatments do you want to discuss? Check any. * Finasteride daily tablet Topical minoxidil (applied to the scalp) Both, if the Clinician recommends them Unsure — help me choose

Finasteride and topical minoxidil can be considered online if you are eligible and your photos and history fit pattern hair loss. Other causes of hair loss, and other treatments that need an exam, procedures, or lab testing, are cared for in person at our Denton clinic — if one of those fits you better, we will explain the next step and help you book.

Step 5 of 13 — Hair loss pattern and history

How your hair loss started and how it has changed.

How old were you when you first noticed hair loss or thinning? *

How long has your hair been thinning? * Less than 6 months 6 to 12 months 1 to 5 years More than 5 years

Where is the thinning? Check all that apply. * Front hairline / temples Crown (top/back of the head) Across the top of the scalp All over the scalp evenly In round or irregular patches Mostly at the sides or back Unsure

Has hair loss or thinning affected your eyebrows, eyelashes, beard, or body hair? * No Yes

If yes, describe — include dates

Do close male relatives (father, brothers, grandfathers, uncles) have pattern hair loss? * No Yes Unsure

If yes, who and at about what age did theirs start?

Have you had a major illness, surgery, hospitalization, major stress, rapid weight change, or a new medicine in the 3 to 6 months before the thinning started? * No Yes Unsure

If yes, describe — include dates and give approximate dates

Do you pull, twist, or break your hair, wear styles that pull tightly, or use harsh chemical treatments, heat, or bleach often? * No Yes

If yes, describe — include dates

Have you ever been told you have alopecia areata, a scalp condition, a thyroid condition, anemia or low iron, or a hormone condition that can affect hair? * No Yes Unsure

If yes, describe — include dates, including any testing or treatment

Step 6 of 13 — Scalp symptom screen

A safety check for symptoms that point to a different cause.

Pattern hair loss is gradual, pain-free, and follows the hairline and crown pattern above, with a healthy-looking scalp. The symptoms in this section can point to a different cause that needs hands-on examination, and sometimes lab testing or scalp treatment first. Answer honestly — checking an item does not end your care; it routes you to the in-person care that fits the cause, where treatment works best.

Explain any item you checked, including when it started

Do you have any of these right now? * Severe headache or vision change Chest pain or trouble breathing Thoughts of harming yourself None of the above

Step 7 of 13 — Finasteride and minoxidil safety screen

This screen helps the Clinician choose safely.

Finasteride and minoxidil are not right for everyone. This screen helps the Clinician choose safely. A "yes" does not automatically end your care; it may mean a different treatment, a video visit, or an in-person visit fits you better.

Explain any item you checked, including dates and current status

PSA history: most recent PSA date and result, if known (write "Never tested" if none) *

Who is your primary care clinician, and when was your last visit and prostate screening discussion?

Have you ever been told not to take finasteride or minoxidil, or stopped either one because of side effects? * No Yes

If yes, describe — include dates what happened

Step 8 of 13 — Health history

Your overall health background.

If yes, describe — include dates

Any surgery, including hair transplant or scalp procedure? * No Yes

If yes, describe — include dates

Family history: prostate cancer, breast cancer, heart disease before age 50, or pattern hair loss in close relatives? * No Yes Unsure

If yes, describe — include dates

Step 9 of 13 — Medicines, allergies, previous hair loss treatment

Everything you currently use, and what you have tried before.

List every prescription medicine, over-the-counter medicine, vitamin, supplement, and recreational substance you currently use. Include dose and how often you take it. Be sure to include any prostate medicine, antidepressant, blood pressure medicine, and any hair, skin, or supplement product. *

Medication allergies or serious reactions (write "None" if none) *

For each treatment you used: how long, how consistently, any benefit, any side effects, and why you stopped

Are you currently using finasteride or minoxidil? If yes, dose, how often, and who prescribed it

Step 10 of 13 — Lifestyle and wellbeing

A few questions about daily life and mood.

Tobacco or nicotine: type and amount per day. Write "None" if none. *

Alcohol: drinks per week *

Cannabis or other recreational substances? * No Yes

Typical sleep: hours per night

Recent major stress, grief, major illness, or rapid weight change? * No Yes Prefer to discuss

During the past 2 weeks, have you often felt down or depressed, or had little interest or pleasure in things? * No Yes

During the past 2 weeks, have you often felt nervous, anxious, or on edge, or been unable to stop worrying? * No Yes

Are you currently thinking about harming yourself or someone else? * No Yes

Mood matters for this care. Finasteride has been reported to affect mood in some men. Tell your Clinician promptly about any new or worsening depressed mood, anxiety, or thoughts of harming yourself, during treatment or after stopping.

Step 11 of 13 — Scalp and hair photos

Required before Clinician review.

Clear photos let the Clinician confirm the pattern of loss and the health of your scalp — this care relies on your history and photos together. Take the photos today, in bright light, with dry hair and no hat, headband, or hair fibers / concealer. Part and comb your hair as the labels describe. Blurry or filtered photos may mean a video or in-person visit is needed before any decision.

Photo 1 — Front hairline (face the camera, hair brushed back so the hairline shows) *

Photo 2 — Top and crown (camera above your head, looking down at the top and crown) *

Photo 3 — Left side / temple (turn so your left hairline and temple show) *

Photo 4 — Right side / temple (turn so your right hairline and temple show) *

Photo 5 — Back of the head (Optional — helpful if thinning reaches the back)

These photos show my hair and scalp as they look today, with no filters, fibers, or concealer. *

Height

Weight

Lab dates and results, if known

Step 12 of 13 — How you will receive medication

Your prescription goes to your own pharmacy for pickup.

If the Clinician prescribes, your prescription goes to your own pharmacy for pickup — recommended for a first fill, and the only option if your ID could not be verified. Your insurance can pay for the medication there.

Pharmacy pickup: * Pharmacy pickup — prescription sent to the pharmacy I name below Mail delivery — Evolve mail plan: one flat total (visit + medication + shipping); mailed in plain packaging, adult signature required.

Mail delivery is available for most medications — not all. Some medications need refrigeration or special handling, and some addresses can't be reached by mail. If mail isn't possible for your medication or your address, we'll tell you before you pay, and your prescription will go to your pharmacy for pickup instead — no extra visit charge.

Pharmacy name and city (for pickup) *

Step 13 of 13 — What happens next + consent

Please read each statement and check every box.

After review, a Clinician may: ask follow-up questions or verify your identity and location; require a video visit to see your scalp and hairline live; request records or lab tests, including prostate screening follow-up where it fits your history; schedule an in-person evaluation for a scalp examination; recommend care for a different cause of hair loss; or explain that online treatment does not fit your case. No medicine is promised.

Payment: your exact price is shown before checkout. Your card is authorized when you submit and The fee covers your Clinician review and is charged once the review is complete, whether or not treatment is approved. Medication, if prescribed, is separate.

If finasteride is prescribed for me, I understand and agree to each statement: * Finasteride can cause sexual side effects in some men, including lower sex drive, erection changes, and ejaculation changes. These may continue after stopping for some men. I will tell my Clinician promptly if they happen. Finasteride can affect mood in some men, including depressed mood. I will tell my Clinician promptly about new or worsening mood changes, and I will call 911 or call/text 988 right away if I have thoughts of harming myself. Finasteride can lower a PSA blood test result. I will tell every clinician who cares for me, and anyone who orders or reviews my prostate screening, that I take finasteride. Pregnancy exposure warning: women who are pregnant or may become pregnant must not handle crushed or broken finasteride tablets, because finasteride can harm a developing baby. I will store tablets safely away from a pregnant partner or household member, keep tablets whole, and follow any additional household caution my Clinician gives me, including guidance about trying to conceive. Possible breast changes — tenderness, enlargement, a lump, or nipple discharge — should be reported to my Clinician promptly. I will not share finasteride with anyone else, and I will not take finasteride 5 mg, dutasteride, or another person's finasteride in place of what is prescribed for me.

If topical minoxidil is prescribed for me, I understand: * Minoxidil is applied to the scalp as directed, on a dry scalp, and is for external use only. I will wash my hands after applying it and keep it away from children and pets. Scalp itching, dryness, flaking, or irritation can happen. If I develop a rash, swelling, chest pain, a racing heartbeat, dizziness, or sudden weight gain, I will stop and seek care promptly. Unwanted hair growth can happen if the product spreads to the face or other areas.

I understand how results are judged: * Hair growth is gradual. Treatment, if prescribed, is judged over time — early review at about 3 months, a clearer view at about 6 months, and a fuller judgment at about 12 months of consistent use. In the first weeks, shedding can increase briefly as hairs cycle — this alone does not mean treatment has failed. I will raise concerns with my Clinician rather than stopping on my own without a message first, unless I have side effects that need prompt care. Benefit, if it comes, is maintained only while treatment continues. If treatment stops, hair gained or kept because of treatment is gradually lost over the following months. No result is guaranteed. Some men stabilize loss, some regrow hair, and some do not respond — my Clinician will review my progress photos and history at follow-up and adjust the plan honestly with me.

Type your full legal name to confirm each statement: * The information I provided is complete and accurate to the best of my knowledge. I listed all medicines, supplements, allergies, and relevant health conditions. I am 18 years of age or older, I am the person named on the ID I uploaded, and I am physically located in Texas during this evaluation. I understand a Clinician may require video, examination, vital signs, records, photographs, or laboratory testing before deciding. I understand submitting this form does not guarantee treatment or a prescription. I understand telehealth has limits and I may be directed to urgent, emergency, specialist, or in-person care. I consent to telehealth care from Evolve Health, including review of this form and my scalp and hair photos, secure messaging, and a video or in-person visit if my Clinician requires one. I will seek emergency care for any emergency warning symptom listed at the top of this form.

Full legal name (acts as your signature) *

Demo e-signature — typed name only; nothing is submitted.

Payment authorization * I authorize Evolve Health to authorize my payment card when I submit. My card is charged the review fee once a Clinician completes my review, whether or not treatment is approved.

⚠ Stop and get urgent care

Step 1 of 13 — Eligibility gates

Step 2 of 13 — About you

Step 3 of 13 — Identity verification

Step 4 of 13 — Your concern and goals

Step 5 of 13 — Hair loss pattern and history

Step 6 of 13 — Scalp symptom screen

Step 7 of 13 — Finasteride and minoxidil safety screen

Step 8 of 13 — Health history

Step 9 of 13 — Medicines, allergies, previous hair loss treatment

Step 10 of 13 — Lifestyle and wellbeing

Step 11 of 13 — Scalp and hair photos

Step 12 of 13 — How you will receive medication

Step 13 of 13 — What happens next + consent

This online form stops here

Demo complete