1 Your details
2 Health info
3 Payment

I acknowledge that I have read and fully understand the risks, limitations, conditions of use, and instructions for use of electronic communication for Services, more fully described in the following link outlining the Risks associated with Electronic Communication. I understand and accept the risks outlined in the aforementioned link, associated with the use of the Services in communications with medical practitioners associated with Your MD Inc. I consent to the conditions and will follow the instructions outlined in this link, as well as any other conditions that medical practitioners may impose on communications with patients using the Services. I acknowledge and understand that despite recommendations that encryption software be used as a security mechanism for electronic communications, it is possible that communications with Your MD Inc. using the Services may not be encrypted. Despite this, I agree to communicate with the medical practitioners using these Services with a full understanding of the risk. I acknowledge that either I or the medical staff may, at any time, withdraw the option of communicating electronically through the Services upon providing written notice. Any questions I had have been answered.

Further, I have read and agree to Your MD Inc.'s Privacy Policy and Terms of Use.

Consent for electronic communication
The following questions will gather your Medical History. This information will be used to determine whether it is safe for us to treat you using telemedicine and whether medical treatments are viable options for you.
Where on the head do you feel you have lost the most hair?
Have you noticed or experienced any of the following in the last 6 months.
Are you experiencing, have experienced, or ever been diagnosed with any of the following?

Our medical team needs good resolution and clear pictures to confirm whether telemedicine can be a suitable form of care for your case. Please upload the following pics. Please use the instructions below:

- Ideally have a family member or a friend take the pics

- Pictures should not be blurry or out of focus

- Focus on the areas of interest (sides, front half, top of the head, back of the head, temples)

$ 39
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