Intakes Combined – Northwestern Access

User ID	Patient First Name	Patient Last Name	Patient Email	Patient Phone	User ID	Patient First Name	Patient Last Name	Patient Email	Patient Phone		Provider ID (Hidden)	Finasteride and Dutasteride are the strongest proven hair loss treatments. Have you tried them?	Which form of finasteride did you try?	Which form of dutasteride did you try?	No previous treatments	Finasteride pills work - but they are more likely to cause sexual side effects than our treatment.	Topical finasteride works great - but we offer something stronger and can save you money.	You're serious about hair loss! - we offer the strongest treatment and can save you money.	Dutasteride pills work - but they are more likely to cause sexual side effects than our treatment.	Topical dutasteride is the best treatment available - but we can save you money.	You're serious about hair loss! - we offer the strongest treatment and can save you money.	Oral treatment works - but it's more likely to cause sexual side effects than our treatment.	User ID	Patient First Name	Patient Last Name	Patient Email	Patient Phone		Provider ID (Hidden)	Are you at least 18 years old and live in Illinois?	What is your current weight in pounds?	Total height in inches	BMI		Have you ever had any of the following conditions?	Do you have a personal or family history of medullary thyroid cancer?	Do you have a personal or family history of Multiple Endocrine Neoplasia type 2 (MEN2)	Are you taking any of the following medications?	Do you have plans to start or grow your family within the next 6 months?
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User ID	Patient First Name	Patient Last Name	Patient Email	Patient Phone	User ID	Patient First Name	Patient Last Name	Patient Email	Patient Phone		Provider ID (Hidden)	Finasteride and Dutasteride are the strongest proven hair loss treatments. Have you tried them?	Which form of finasteride did you try?	Which form of dutasteride did you try?	No previous treatments	Finasteride pills work - but they are more likely to cause sexual side effects than our treatment.	Topical finasteride works great - but we offer something stronger and can save you money.	You're serious about hair loss! - we offer the strongest treatment and can save you money.	Dutasteride pills work - but they are more likely to cause sexual side effects than our treatment.	Topical dutasteride is the best treatment available - but we can save you money.	You're serious about hair loss! - we offer the strongest treatment and can save you money.	Oral treatment works - but it's more likely to cause sexual side effects than our treatment.	User ID	Patient First Name	Patient Last Name	Patient Email	Patient Phone		Provider ID (Hidden)	Are you at least 18 years old and live in Illinois?	What is your current weight in pounds?	Total height in inches	BMI		Have you ever had any of the following conditions?	Do you have a personal or family history of medullary thyroid cancer?	Do you have a personal or family history of Multiple Endocrine Neoplasia type 2 (MEN2)	Are you taking any of the following medications?	Do you have plans to start or grow your family within the next 6 months?