Medical History Form for Hair Loss Treatment

Medical History Form

For Prescription Only Products ( RPM DERMA Rx)
Please complete this form as best and accurate as possible. Ensure that your contact details are up to date, as our clinician may need to contact if more information or clarification is needed.
- I am over 18 years old.
- I will see my GP if I need help completing this form, reading or understanding this consultation.
- I am using this service on my own behalf and of my own free will, and any treatment or advice is for my sole use only.
- I understand that my prescription will not be approved until a clinician has reviewed and confirmed suitability for minoxidil.
- I understand that every product has limited shelf life ( expiry time) and I noted how long the ingredients of product I am buying today have guranteed effciency ( cream and gels - 30 days or hair solution 6 months , unless stated otherwise )
I have read and understood the information listed above
Full Name*

First NameLast Name
What sex you were born with?*
Date of birth *

DayMonthYear
Date
Contact Number*
i.e. 0730 1111 111
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Check the conditions that apply to you or any member of your immediate relatives:*

AsthmaCancerCardiac diseaseDiabetesThyroid diseaseHypertensionAnxiety or DepressionEpilepsyNOT Diagnosed or investigated for any medical conditionsOther
Are you currently taking any medication?*

YesNo
Please list them.
Do you have any medication allergies?*

YesNoNot Sure
Please list them.
Do you use any kind of tobacco or have you ever used them?
What kind of tobacco products? How long have you used/been using them?
Do you use any kind of illegal drugs or have you ever used them?
What kind of drugs? How long have you used/been using them?
How often do you consume alcohol?

DailyWeeklyMonthlyOccasionallyNever
WHAT IS YOUR CONCERN TODAY ?*

Hair and Beard areaSkin Condition

Have you tried or been prescribed any treatment for your symptoms?*

YesNo
Please give details
Please upload clear and sharp photos of concerned areas. You can upload multiple photos at once.*

Cancelof
Acknowledgement

By submitting this form, you declaring that all the information provided is true and complete to the best of your knowledge. You confirm that you have not omitted any details that could affect your ability to receive treatment or safely use the product. You understand that providing inaccurate or incomplete information may impact the safety and effectiveness of your treatment.
Date

DayMonthYear
Date
Should be Empty: