Explain your symptoms or tell us how we can help today.*

Do you have allergies to any medications?*

Yes
No

If yes, please list any medications you have allergies to:

Are you pregnant or breastfeeding?*

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Unfortunately we cannot proceed with your request based on the information you have provided.

What symptoms have you been experiencing recently?*

Itchy scalp
Dry scalp
White flakes or shedding skin of scalp
Red or discolored patches on the skin
Thick patches of skin on scalp (plaques)
Other
I don’t have any of these symptoms

If you've listed "other", please explain your symptoms:*

How Long have you been having these symptoms?*

Started today
1-3 days
4-7 days
Over 1 week

Have you ever been treated for dandruff?*

Yes
No

How long ago?*

What medications were you treated with?*

Pyrithione zinc shampoo
Tar-based shampoo
Salicylic acid shampoo
Selenium sulfide shampoo
Ketoconazole shampoo
Other

Please list the treatment plan:*

Did treatment work?*

Yes
No

Would you prefer the same treatment?*

Yes
No
Leave to doctor’s discretion

Smoker?*

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No
Never

Alcohol use?*

Any medical family history?*

Yes
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