Private Prescription Request (Hair Loss) (YEHS)

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Private Prescription Request (Hair Loss)
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Full Name* This field is required.
First Name
Last Name
3
Phone Number* This field is required.
Area Code
Phone Number
4
E-mail* This field is required.
example@example.com
5
Date of Birth* This field is required.
Date
Day
Month
Year
6
What gender were you assigned at birth?
Male
Female
7
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
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Aruba
Australia
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New Caledonia
New Zealand
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Niger
Nigeria
Niue
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Paraguay
Peru
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Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
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Saint Helena
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Senegal
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eSwatini
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Other
Country
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Your Allergies* This field is required.
Please add your medication and non-medication allergies
9
What are your medical problems?* This field is required.
10
Please list the medication you take regularly?* This field is required.
11
What is your Blood Pressure(BP)?
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Doctors Name OR Name of Practice/Clinic* This field is required.
Dr Ade Buluro (YEHS)
Others
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If you selected Other, fill your Doctors Name/Practice below:
Please add the name of your Doctor and/or the name of their practice/clinic here
14
If you selected Other, fill your Doctors Email Address
example@example.com
15
If you selected Other, fill your Doctors Phone Number
Area Code
Phone Number
16
Will you be ordering Finasteride or Dutasteride?* This field is required.
Yes
No
17
What gender were you assigned at birth?
Male
Female
18
Are you above 18 years old?
Yes
No
19
Do you have any hypersensitivity to Finasteride or Dutasteride?
Yes
No
20
Do you have severe liver problems?
Yes
No
21
Do you have any fertility issues such as low sperm count?
Yes
No
22
Do you acknowledge that women of childbearing potential, pregnant and nursing women will avoid handling Dutasteride or Finasteride?
Yes
No
23
Does you acknowledge that condom are recommended if your sexual partner is pregnant or likely to become pregnant?
Yes
No
24
Is the patient Hypertensive or on blood pressure medication?
Yes
No
25
We are Sorry!

But based on your entry, you are not eligible to purchase Dutasteride or Finasteride online. Please arrange a consultant with our specialist to discuss further
26
Will you be ordering Minoxidil?* This field is required.
Yes
No
27
Are you hypertensive or taking blood pressure medication
Yes
No
28
Please confirm you will keep alcohol intake minimal while taking Minoxidil because alcohol and Minoxidil both lower blood pressure?
Yes
No
29
Will you be ordering other Hair Loss Medications?* This field is required.
Yes
No
30
Medication Request
prevnext( X )
My Bag
1
My Bag
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
ORDER SUMMARY
Total costGBP
Medication Request
£20.00Edit
Back
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Quantity
Avodart 0.5mg Tablet 30 Tablets (Dosage - Take one tablet daily).
£50.00Edit
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Quantity
Avodart 0.5mg Tablet 90 Tablets (Dosage - Take one tablet daily).
£120.00Edit
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Quantity
Finasteride 1mg Tablet 28 Tablets (Dosage - Take one tablet daily).
£20.00Edit
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Quantity
Finasteride 1mg Tablet 84 Tablets (Dosage - Take one tablet daily).
£45.00Edit
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Quantity
Finasteride 5mg Tablet42 Tablets (Dosage - Take half tablet on alternate days).
£35.00Edit
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Quantity
Minoxidil 5.2%120ml lotion x 3 Bottles (Apply 1ml to affected areas of scalp twice daily)
£67.00Edit
Back
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Quantity
Minoxidil 5.2% plus Panthenol 1:800120ml lotion x 3 bottles (Dosage - Apply 1ml to affected areas of scalp twice daily)
£67.00Edit
Back
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Quantity
Minoxidil 5.2% plus Progesterone 1:800120ml lotion x 3 bottles (Dosage - Apply 1ml to affected areas of scalp twice daily)
£67.00Edit
Back
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1
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Quantity
Minoxidil 6%120ml lotion x 3 bottles (Dosage - Apply 1ml to affected areas of scalp twice daily)
£67.00Edit
Back
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1
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Quantity
Minoxidil 6% plus Panthenol 1:800120ml lotion x 3 bottles (Dosage - Apply 1ml to affected areas of scalp twice daily)
£67.00Edit
Back
1
1
2
3
4
5
6
7
8
9
10
Quantity
Minoxidil 6% plus Progesterone 1:800120ml lotion x 3 bottles (Dosage - Apply 1ml to affected areas of scalp twice daily)
£67.00Edit
Back
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1
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Quantity
Propecia 1mg Tablet84 Tablets (Dosage - Take one tablet daily)
£150.00Edit
Back
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1
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Quantity
Propecia 1mg Tablet168 Tablets (Dosage - Take one tablet daily)
£310.00Edit
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Quantity
Tretinoin 0.05%30ml serum (Dosage - Use sparingly on affected areas as directed)
£29.95Edit
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Quantity
Postage (Courier)
£7.95Edit
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Quantity
Total cost £0.00
First Name
Last Name
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Date
Date
Day
Month
Year
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