Preliminary questions, Let’s start with some Preliminary questions, How much hair have you lost? *Minimal – Just a bit of thinning; others might not even notice.Mild – Noticeable thinning in certain areas (hairline temples or crown).Moderate – Visible hair loss with reduced density across larger areas.Significant – Clearly thinning or balding patches that are easy to see.Extensive – Advanced hair loss or large balding areas.Since when have you experienced hair loss? *Less than 3-6 monthsMore than 6 monthsMore than 2 yearsCan't recall - it has been a whileWhat kind of hair loss are you experiencing? *Receding hair linePatchy hair lossThinning and diffuse (all over the scalp) hair lossSheddingOther---------------------------------------Please explain *How has your hair loss progressed over time? *Stable (no significant change)Gradually worseningRapidly worseningIrregularUnsureDo you have a history of any of the following medical conditions? *Chronic medical conditions can influence which hair loss treatments are safe and appropriate for you. Providing accurate information helps our clinical team assess potential risks, avoid contraindications, and ensure your treatment plan is medically suitable.Heart or coronary artery diseaseRespiratory diseasesGastrointestinal diseaseLiver diseaseKidney Disease or dialysisRheumatological or autoimmune conditionsHormonal / endocrine or thyroid disordersCancerOthersI do not have any other condition---------------------------------------Please describe the nature of your cardiovascular condition *Please describe the nature of your respiratory disorder *Please describe the nature of your GI disorder *Please describe the nature of your kidney condition *Please describe the nature of your rheumatological or autoimmune condition *Please specify which endocrine/hormonal or thyroid disorder you have *Please describe the details of your oncologic condition *Please specify your condition *Do you have any of the following nutritional deficiencies? *Certain nutrient deficiencies can contribute to hair loss. This information helps the physician identify potential underlying causes and guide appropriate treatment.Iron deficiency or low ferritinVitamin D deficiencyVitamin B12 deficiencyZinc deficiencyOtherNone of the aboveI am not sureOthersI do not have any other condition---------------------------------------Please specify *Have you had major trauma, significant weight loss, surgeries or hospitalizations in the past 6 months? *Recent illness, trauma, or major health changes can trigger telogen effluvium, a common reversible cause of hair shedding. This information helps the physician identify contributing factors and guide appropriate treatment.YESNO---------------------------------------Please specify *Are you currently pregnant, planning a pregnancy or breastfeeding? *Certain hair loss medications, including finasteride and some oral treatments, are not safe during pregnancy or breastfeeding and may pose risks to the developing baby. Knowing this information allows our clinical team to recommend only treatments that are medically appropriate and safe for your situation.YESNoI am not sureDo you have family history of hair loss? *A family history of hair loss can help identify the cause and pattern of your hair thinning. This information assists the physician in confirming the diagnosis and selecting the most effective treatment approach for you.YesNoHave you used any of the following hair loss treatments before? *Understanding which treatments you’ve tried and how you responded helps our clinical team determine what may be effective for you and avoid prescribing options that previously caused side effects or did not work.SupplementsPRP therapyLaser therapyHair TransplantPrescription medicationOthers---------------------------------------Please provide details about your previous hair transplant *Please include the date of your procedure, the type of transplant, and your results or any concerns.Please provide details *Specify the medication, when you last took it, its effectiveness, and any side effects.Please specify *Are you interested in trying oral minoxidil? *YESNOI am not sure I need a consultAre you currently taking any other medications or supplements? *Current medications may interact with hair loss treatments or affect their safety. Listing all medications you take helps the physician avoid contraindications and choose the most appropriate treatment for you.YesNo---------------------------------------Please specify *Please name the medication, which condition it is for, dosage/prescription, frequency and any side effects you may be experiencingDo you have any known allergies? *YESNOAllergies can affect which medications are safe for you.---------------------------------------Please specify *List the allergen, your reaction, and any treatment received so the physician can ensure safe prescribing.How would you describe your overall diet and nutritional intake? *Well-balanced diet (regular protein fruits vegetables healthy fats)Low protein or inconsistent mealsLow in essential nutrients (iron vitamins minerals)Frequent restrictive dieting or calorie deficitsHigh processed foods / low whole foodsNot sure / prefer not to sayDiet quality can influence hair growth and overall scalp health.How would you describe your stress levels? *High stress levels can contribute to hair shedding and may influence your treatment plan. Understanding your stress helps the physician identify contributing factors and guide appropriate care.LowModerateHighExtremely highDo you consume alcohol, use tobacco products, or use any recreational drugs? *Alcohol, tobacco, and recreational drug use can affect hair health and may interact with certain medications. This information helps the physician assess contributing factors and ensure safe treatment planning.YESNO---------------------------------------Please specify *Which drug and frequency?What is your most recent blood pressure reading? *Must be within last 6 monthsLow blood pressure (below 90/60)Normal (90/60 to 119/79)Slightly elevated (120–129 / under 80)High blood pressure – Stage 1 (130–139 / 80-89)Very High blood pressure – Stage 2 (140+ / 90+)I’m not sure / I don’t check it regularlyIs there any additional medical information, questions or requests for the doctor that you’d like to include? *Do you have a preferred hair-loss treatment option? *Your preference helps guide the clinician, but recommendations will depend on what is medically appropriate for you.Oral treatments (Minoxidil / Finasteride): Starting $179Topical formulations (Minoxidil / Finasteride): Starting $169Combination of oral and topical treatmentNo preference - open to the best optionI am not sure - I need guidanceMedication counselling? *Please select if you would like counselling with a ClinicianPreferred Callback Time *A callback is an essential next step. Within 24–48 hours, our Clinical Care Coordinator will contact you to verify your information and guide you through the remaining steps of your assessment.Weekday morningsWeekday afternoonsWeekday eveningsWeekends registration form GenderMaleFemalePrefer not to sayPlease upload a clear photo of your scalp showing the affected area *Telehealth standard of care - This step helps our clinicians ensure the information you’ve provided matches your profile and supports safe prescribing. Your photo remains private and protected at all times. Your information is encrypted and stored securely under PHIPA and PIPEDA guidelines.Drag and Drop (or) Choose FilesPlease provide a clear photo of your valid Ontario Health Card *Our team uses this only to confirm your identity and ensure you receive any OHIP-covered benefits you may be eligible for. Your information remains private and fully protected.Drag and Drop (or) Choose FilesPlease upload a photo of a valid Ontario government-issued ID (Driver’s License, Photo Card or Passport) *This helps us verify your identity and maintain a safe, compliant clinical process. Your ID is used only for verification and is securely stored under Ontario privacy regulations.Drag and Drop (or) Choose FilesWhat happens next… 1. Payment Processing: The CA $40 telehealth assessment fee is collected upfront to begin the assessment. 2. File Review: Your intake is securely reviewed and prepared by the care coordination team. 3. Physician Assessment and Prescription: A licensed physician reviews the assessment to determine if treatment is appropriate. If approved, a prescription is issued. 4. Medication Fulfillment: Medication is dispensed by a licensed pharmacy and delivered discreetly. 5. Ongoing Support: Support is available for follow-ups, renewals, and treatment adjustments.Disclaimer .... A $40 Telehealth assessment fee applies to all new visits and renewals. This is not a physician fee. It covers Rumini’s secure clinical intake review, care coordination, administrative processing, access to our virtual care platform, and free, discreet delivery of your medication once prescribed. This fee supports the convenience and privacy of fast, online care - it is non-refundable once the assessment has been reviewed. Hair loss medications are billed separately once your prescription is approved, with pricing varying based on the treatment and strength selected.Consent - By clicking Submit, you accept our Terms of Use and Privacy Policy, (accessible on www.rumini.ca) and provide consent for Rumini to securely collect and process your information through virtual care. You also confirm that all information provided is true, accurate, and complete to the best of your knowledge.Rigister Start Your Free Hair Loss Assessment
