Medical Assessment Form
Hair loss
Patient details
First Name
Last Name
Your details
Date of birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
Region
Postcode
Phone Number
Please enter a valid mobile phone number- this will be used to send a payment link should supply be approved as well as for any queries the prescriber may have.
Format: 00000 000000.
Which GP surgery are you registered with
Would you like us to contact your GP to inform them of this consultation?
Yes
No
Are you male and aged 18 or over
*
yes
no
Are you experiencing progressive (non sudden) male pattern hair loss as shown in figures II to VA in the Norwood scale diagram? Figure 1 shows a hairline with no such hair loss.
yes
no
If you're unsure whether you have male patter baldness, send us a photo:
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Do you suffer from any allergies? Please state them or type "none"
Do you have any medical conditions? Please state them or type "none"
Are you taking any medication? Please mention *any* that you take or use, whether on prescription or bought over the counter, or whether they are to do with hair loss or anything else.
Have you had a hair transplant
*
Yes
No
Please read the following important information and confirm that you will follow the advice should you be approved for supply with finasteride through this service. *The MHRA has received reports of depression, anxiety and, in rare cases, suicidal thoughts in men taking finasteride for Male pattern hair loss. Mood alterations including depressed mood, depression, anxiety and, less frequently, suicidal ideation have been reported in patients treated with finasteride 1 mg– Patients should inform the prescriber should any such symptoms occur and be advised to seek medical advice•
*
I agree
The pharmacist as part of this consultation has permission to confirm your identity and access your summary care record to ensure the service is clinically safe and effective. After pressing "submit" the form will be reviewed by the pharmacist who will review it and contact you.
I agree
Submit
Should be Empty: