Hair Loss

1

Full Name* This field is required.

First Name

Last Name

2

Email Address* This field is required.

example@example.com

3

Phone Number* This field is required.

4

Date of Birth* This field is required.

Date

5

Are you suffering from hair loss?* This field is required.

Yes

No

6

Do you have hair loss in patches, or have an itchy or sore scalp?* This field is required.

Yes

No

7

Do you have a healthy scalp?* This field is required.- No inflammation on the scalp - No redness - No medical dressings - Unshaven

Yes

No

8

Do you have sudden unexplained hair loss or complete hair loss?* This field is required.

Yes

No

9

Could your hair loss be explained by any medication or illness (e.g. chemotherapy)?* This field is required.

Yes

No

10

Have you ever been diagnosed with one of the following conditions:* This field is required.- Prostate problems (prostate enlargement, prostatitis, prostate cancer) - Male breast cancer - Heart Disease (including chest pain, angina, heart attack or any history of cardiovascular event) - High Blood Pressure - Chronic liver disease (including liver cirrhosis) - Pheochromocytoma (cancer of the adrenal glands) - Acute Porphyria (a rare hereditary disease affecting haemoglobin)

Yes

No

11

Are you allergic/hypersensitive to minoxidil, finasteride/propecia, caffeine, ethanol, propylene glycol or lactose?* This field is required.

Yes

No

12

Have you ever had or are you currently experiencing low mood, depression or suicidal thoughts?* This field is required.

Yes

No

13

Do you currently have any sexual health concerns including low libido (sexual desire) or erectile dysfunction?* This field is required.

Yes

No

14

Are you currently taking any medications like finasteride e.g. dutasteride (Avodart)?* This field is required.

Yes

No

15

Do you agree to the following?* This field is required.You understand that research suggests a possible link between finasteride and depressive symptoms, suicidal thoughts, and sexual problems (such as reduced sex drive, erectile dysfunction, and ejaculation issues), although this connection is still being studied. You understand that if you develop depression, suicidal thoughts, or sexual dysfunction, you must stop treatment and seek urgent medical advice. You understand that sexual dysfunction may in rare cases persist in some people even after stopping finasteride. You will seek medical review if you notice changes in your breast tissue including lumps, pain or nipple discharge. You understand that finasteride can affect Prostate Specific Antigen (PSA) test results, so you will tell your doctor you are taking this medication before having this test. You will read the patient information leaflet supplied with your medication You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment. The treatment is solely for your own use. You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.

Yes

No

16

Do you understand that if prescribed finasteride:* This field is required.You must take steps to avoid conception while using this medication, such as always using a condom during sex. If your partner is pregnant or could become pregnant, they must not handle crushed or broken tablets, as this could harm the pregnancy.

Yes

No

17

Declaration & Consent* This field is required.

I understand that these products are not a substitute for medical diagnosis or treatment.

I confirm that the information I have provided is accurate and complete.

18

Appointment* This field is required.