Hair Loss Treatment Intake & Consent Form

Hair Loss Treatment Intake & Consent Form

Share your details, confirm suitability, review side effects and usage instructions, and acknowledge consent and purchase terms.
Section 1: Patient Details
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Sex (assigned at birth)
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: 00000000000.
Section 2: Medical History & Suitability Screening
Do you have any allergies? If yes, please list them.
Are you currently taking any medications or do you have any medical conditions, including mental health conditions such as depression/ anxiety, suicidal thoughts? Please specify.
Do you currently have or have had any liver, kidney or prostate problems?
Please specify
Do you suffer from hair loss?
Have you been formally diagnosed with hair loss?
How long have you suffered with hair loss?
Do you have a family history of hair loss?
What pattern of hair loss are you experiencing?
Have you used any hair loss treatments before?
Which treatments have you tried?
Were the treatments effective?
Did you experience any side effects?
Please describe the side effects
Do you suffer from any scalp conditions such as dandruff, psoriasis, folliculitis, etc? If yes, please specify
Are you pregnant, planning to become pregnant, or breastfeeding?
Please upload clear photos of the hair loss areas

Cancelof
Do you already know which treatment you're interested in, or would you like guidance from a prescriber first?
Formula selected
Estimated total
Please mention any treatment you are interested in, including any strengths you'd like to request
Please add any other comments you may have
Identity Verification

As we prescribe prescription-only medicines, we're required to verify your identity before treatment can be issued. Please upload the two items below.
We ask for this now so that, if your prescriber does recommend treatment during your consultation, there's no delay in dispensing it afterwards.
Photo ID (Passport or Driving Licence)

Please upload a clear photo showing your full name, date of birth, and photo, with all four corners visible.
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Selfie Photo: Please upload a clear, well-lit photo of your face taken today, so we can confirm it matches your ID.
Disclaimer: Your ID and selfie are used solely to verify your identity in line with GPhC prescribing requirements and are handled in accordance with our Privacy Policy. This information is not shared with third parties beyond what is necessary to deliver your care, and is retained only for as long as required for our regulatory record-keeping obligations.
Book consultation
Click here to choose a consultation time. Once booked, please return to this tab and click Submit to send us your information ahead of your appointment.
Side effects
Although side effects with topical formulations may be less common than oral medication, they are still possible.

Please note: the treatments offered may be unlicensed medicines ('specials'), prepared specifically for you following clinical assessment.

Finasteride/ Dutasteride (oral and topical): may cause: sexual side effects including reduced libido, erectile dysfunction, and reduced ejaculate volume, breast tenderness/enlargement (gynecomastia); reduce sperm count, motility, or semen volume in some men; psychiatric side effects including depression, anxiety, mood changes, and — in rare cases — suicidal thoughts; these sexual and psychiatric side effects have been reported to persist even after stopping treatment in a minority of cases.

Finasteride/Dutasteride can be absorbed through the skin. Women who are pregnant, or who may become pregnant, must avoid contact with the treated area of my scalp and with any semen exposure during sex, as absorption may cause harm to a male unborn baby's genital development. Avoid sexual contact with a pregnant partner without a barrier method (e.g., condom) while using this product, and tell any female partner of childbearing age about this risk. Please see NHS information

Minoxidil (topical): may cause: scalp irritation, itching, dryness or flaking; unwanted hair growth on adjacent skin (face, ears) if the product spreads beyond the scalp; initial shedding in the first weeks of use (a known, usually temporary effect); rare cases of lightheadedness or rapid heartbeat if absorbed systemically. Please see NHS information

Cetirizine / Melatonin (topical): may cause: local scalp irritation, redness, itching, dryness, or burning at the application site; contact dermatitis or sensitivity to the active ingredient or other ingredients in the formulation may occur. Topical cetirizine has generally been well tolerated in the limited clinical studies available, with few treatment-related adverse effects reported. Topical melatonin has also generally shown good tolerability in clinical studies, although evidence on long-term safety remains limited.

Because these treatments are applied to the scalp, systemic effects are expected to be limited, but systemic absorption cannot be assumed to be zero. If you develop persistent or severe irritation, swelling, a rash, or other unexpected symptoms, stop treatment and speak to your prescriber.

Tretinoin (topical): may cause: skin redness, peeling, dryness, and irritation, particularly in the first weeks ("purging"); increased sensitivity to sunlight and sunburn risk; avoid other exfoliating/retinoid products concurrently unless advised; must not be used if pregnant or breastfeeding. Avoid direct contact with pregnant partners.
Disclaimers
Results & Continued Use Disclaimer

Results from medications and topicals vary significantly between individuals, and no specific outcome or degree of hair regrowth is guaranteed.

Visible results, if any, typically take 3–6 months of consistent use to appear, and full results may take up to 12 months.

Increased shedding is common in the first few months of treatment and is usually a normal part of the hair cycle restarting, not a sign it's failing. Contact us if it's severe or doesn't settle.

Continued use is required to maintain results - hair loss is likely to resume within months of stopping treatment, returning to what it would have been without treatment.

Some individuals may not respond to treatment at all.

Full terms and conditions can be found here Terms & Conditions

Returns and refund policy can be found here, Refund & Returns policy
Declaration and Confirmation
I confirm that:
- The information I have provided in this form is accurate and complete to the best of my knowledge
- I consent to treatment as prescribed, based on the information I have provided
- I agree to inform HairRx Clinic promptly if any of the information provided in this form changes — including but not limited to new medications, new diagnoses, pregnancy, or any other change that may affect the suitability or safety of this treatment for me.
Name

First NameLast Name
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
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Hair Loss Treatment Intake & Consent Form

Section 1: Patient Details

Section 2: Medical History & Suitability Screening

Identity Verification

Book consultation

Side effects

Disclaimers

Declaration and Confirmation