Male Hair Loss

1

Gender:

Male

Female

2

Personal Info* This field is required.Please leave your information for prescription

First Name

Last Name

Please enter your email

Address

Eircode

PPSN

Phone Number

3

Date of Birth* This field is required.

Date

4

Please input your height(cm)* This field is required.

5

Please input your weight(kg)* This field is required.

6

Do you smoke?* This field is required.

Yes

Never smoked

Ex- smoker

7

How many cigarettes per day?

8

Do you have any past medical conditions? (i.e. diabetes/hypertension /asthma/ect.)* This field is required.

Yes

No

9

Please enter your medical condition

10

Except from the above medical condition, Do you have any liver problem?

Yes

No

11

Please advise reason of liver problem.

12

When did you last had blood tests for your liver problem?

13

Is it stable?

Yes

No

14

Do you have any kidney problems?

Yes

No

15

Please advise reason of kidney problem.

16

When did you last had blood tests for your kidney problem?

17

Is it stable?

Yes

No

18

Have you had any heart problems, such as angina (chest pain) or a heart attack?

Yes

No

19

Please describe your heart conditions.

20

Have you ever had a stroke or 'mini stroke'?

Yes

No

21

Please describe your history of stroke conditions.

22

Have you ever had any major surgery?

Yes

No

23

Please describe your surgical conditions.

24

Are you allergic to any medication or do you have any allergies?* This field is required.

Yes

No

25

Please enter things you allergy about

26

Are you taking any medication? This includes none-prescription, over-the-counter medicines as well as herbal remedies?* This field is required.

Yes

No

27

Please lists your medications?

28

Does anyone in your family have male pattern baldness; this can be on either your mother's or father's side?* This field is required.

Yes

No

29

Please advise who in your family had male pattern boldness

30

How long have you been affected by hair loss?* This field is required.

< 1 month

1-6 month

> 6 months

31

How did your hair loss begin?* This field is required.

Started suddenly

Gradual loss

32

If your hair loss occurred suddenly please give more details (e.g. was there are sudden illness or incident?)

34

Do you have any itchy or rough or scaly patches on your scalp?* This field is required.

Yes

No

35

Do you need further advise on treatment for scaly itchy scalp?

Yes

No

36

You can book appointment with GP online to discuss about your hair scaly itchy scalp to consult regarding causes of this and treatment.

Please book appointment online https://www.gpdoc.ie .

37

Has your hair loss affected any other body parts (e.g. eye brows, genital or underarm areas)?* This field is required.

Yes

No

38

Apart from the issues already mentioned, were you ever treated for any previous Accidents, Operations, Investigations or Illnesses? Do you have anything you felt information necessary to inform us?* This field is required.

Yes

No

39

If yes, please enter your concerns:You could upload any relevant files or images in the next page

40

Upload any relevant files or images

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

41

Please select the pharmacy that you want for prescription

42

If you are unable to locate your pharmacy, kindly provide the name here (write "null" if you have found it).* This field is required.

43

I confirm that I have read and understood this and my answers are fully correct and true.* This field is required.

I confirm

I do not confirm

44

Please kindly book Video/Face to Face Appointment to discuss further.

You can book online at here

45

Sorry . This form is for Male

Female hair loss will coming soon...

You could book an appointment with Doctor, the link is below:

https://www.gpdoc.ie/

46

Before continuing you must agree to Gpdoc Terms & Conditions.* This field is required.

I agree

I don't agree

47

Please kindly read information about finasteride.

Click here

Once you finished, Please click "Next"

48

I hereby confirm I have read and I agree with all the terms and condition of GPDoc and all the indications and side effects as per previous page and have all the information required to proceed with prescription for finasteride.

I agree

I don't agree

49

Consultation checkout

My Bag

1

Repeat - Prescription FeeFinasteride
€35.00Edit
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