Hair Loss Treatment

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I confirm that I am 18 years of age or older, using this service voluntarily and on my own behalf. Any treatment or advice provided is intended solely for my personal use.* This field is required.
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Prescription Consultation* This field is required.
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ORDER SUMMARY
Total costEUR
Prescription ConsultationOnline Consultation Fee
€25.00Edit
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partner
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Burkes Pharmacies* This field is required.If Successful Your Script will be sent to this pharmacy.
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Havens Pharmacy Macroom
Carrigtwohill Pharmacy
I prefer sending to another pharmacy
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McGorisks Pharmacies* This field is required.If Successful Your Script will be sent to this pharmacy.
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McGorisks Pharmacy, The Crescent
McGorisks Pharmacy, Clonbrusk
McGorisk's Pharmacy, Ballinasloe
McGorisks Pharmacy, Athlone
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Tom Pharmacies* This field is required.If Successful Your Script will be sent to this pharmacy.
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1
2
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Molloy Pharmacies* This field is required.If Successful Your Script will be sent to this pharmacy.
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Molloys Pharmacy - Garden Street, Ballina, F26 W951
Molloys Pharmacy - Bunree Road, Ballina, F26 Y9PF
Molloys Pharmacy - Main Street, Crossmolina, F26A4E3
Molloys Pharmacy - The Harrison Centre, Roscommon, F42 H002
Molloys Pharmacy - Ballaghaderreen, Co. Roscommon, F45X896
Molloys Pharmacy - Knocknacarra, Co. Galway, H91VPX2
Molloys Pharmacy - Davitt Quarter, Achill Island, F28V4P0
Molloys Pharmacy - Claremorris, F12RX02
I prefer sending to another pharmacy
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Scanlon Pharmacies* This field is required.If Successful Your Script will be sent to this pharmacy.
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SCANLONS PHARMACY, ENNIS RD BRANCH
SCANLONS EXPRESS LATE NIGHT PHARMACY, DOCK ROAD
SCANLONS PHARMACY, CASTLETROY BRANCH
LIMITLESS HEALTH PHARMACY
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Full Pharmacy Name and Address is Required* This field is required.If Successful Your Script will be sent to this pharmacy.
If you do not provide correct details your application may be denied.
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Name* This field is required.
First Name
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Email* This field is required.
example@example.com
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Address* This field is required.
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Date of Birth* This field is required.
Date
Day
Month
Year
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Phone Number* This field is required.
Area Code
Phone Number
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Please specify your gender.* This field is required.
MALE
FEMALE
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What level of male pattern baldness are you currently suffering from?* This field is required.
Please Select
Please Select
Stage 1 . No significant hair loss or recession of the hairlines
Stage 2 . There is a slight recession of the hairline around the temples. This is also known as adult or mature hairlines.
Stage 3. The first signs of clinically significant balding appear. The hairline becomes deeply recessed at both temples, resembling an M, U, or V shape
Stage 4 Vertex. The hairline stays at stage 2, but there is significant hair loss on the top of the scalp (the vertex).
Stage 5. The hairline recession is more severe than in stage 2, and there is sparse hair or no hair on vertex. The two areas of the hair loss are sparse
Stage 6. The two areas of the hair loss are larger than in stage 3. They are still separated, but the band of the hair between them is narrower and sparse.
Stage 7. The balding areas at the temples join with balding area at the vertex. The band of the hair across the top of the head is gone or sparse.
Stage 8. The most severe stage of the hair loss, only a band of hair going around the sides of the head remains. This hair is usually not dense.
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How long have you been suffering from male pattern baldness?* This field is required.
Please Select
Please Select
Less than 1 month
1-6 months
Over 6 months
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Did you start losing hair suddenly or gradually?* This field is required.
Gradual Loss
Other
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Do you have any rough, scaly patches or any itchiness on your scalp?* This field is required.
YESNO
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Do you have hair loss on any other part of your body (e.g. Face, eye brows, chest or armpits)?* This field is required.
No
Other
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Do you have any past medical and surgical history that you want to inform our doctor?* This field is required.
No
Other
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Do you have any of the following medical conditions?* This field is required.
NONE OF THE LISTED MEDICAL CONDITIONS
PSORIASIS
RHEUMATOID ARTHRITIS
SYSTEMIC LUPUS ERYTHEMATOSIS (SLE OR LUPUS)
AUTOIMMUNE DISEASE
OTHER CONNECTIVE TISSUE ILLNESSES
Other
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Do you have any family history of male pattern baldness?* This field is required.
YESNO
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Do you smoke cigarettes?* This field is required.
No I do not smoke
Yes, under 5 a week
Yes, under 10 a week
Yes, under 5 a day
Yes, under 10 a day
Yes, under 15 a day
Yes, under 20 a day
Yes, over 20 a day
Other
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Have you used Finasteride, Fintid, Proscar or Profal before? If YES please specify any side effects.* This field is required.
NO
NOT ANYMORE
YES - LESS THAN 6 MONTHS
YES - MORE THAN 6 MONTHS
YES - MORE THAN 1 YEAR
Other
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Are you currently taking any prescription, non prescription or illegal drug or herbal medication and have you recently taken any medication in the last two weeks?* This field is required.
NO
Other
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Attach a File/Photo of Your Regular Medications/Script (Optional)
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Max. file size: 10.6MB
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Attach a File/Photo of Your Scalp to Help the Diagnosis & Treatment (Optional)
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Max. file size: 10.6MB
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Declaration of consent.
I understand the mentioned questions and I have answered them truthfully and to the best of my knowledge.
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GDPR Consent Form* This field is required.To assist with your care, we at Dooctor.ie need to collect personal data about you. This information will include details of your health and your treatments. We may also need to record additional information that while may not seem to relate directly to your health it would help in our treatment of you. Examples of this kind of information would include things like your age, gender, marital status, number of children you have, your nationality, your employment status, religion, prison sentences. Our policy is only to collect and record information about you that helps in your treatment. Declaration  I understand my health information will be seen or shared only with medical and administrative staff involved in my care or where Dooctor.ie is required to do so by law.  I understand that for the purposes of my treatment administrative staff may have to access my health data. Reasons for this access would include the re-issuance of prescriptions, the opening of letters and recording of information from hospitals about me, downloading and saving in my file results from laboratories, typing of letters to hospitals and other similar health related issues.  I understand that all Dooctor.ie staff sign a confidentiality agreement that binds them not to disclose my details to any unauthorised persons not involved in my care.  I understand that any health data shared outside of the practice for the purposes of my health treatment will, normally, be limited to information related to a particular treatment and not my entire file.  I understand that my health data will be stored primarily on a secure database operated by a specialist company called Clanwilliam Health and I understand that Clanwilliam Health are only allowed process my health data under Dooctor.ie instructions.  I understand the law provides that in certain instances personal health information can be disclosed, e.g. in the case of some infectious diseases.  I understand that Dooctor.ie will only release information to, for instance solicitors or insurance companies, at my express request.  I understand that I can withdraw consent for processing of my personal health data at any time.
I confirm my consent.
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