We will ask you a few questions to assess your suitability for prescription hair loss medication.
It should take approximately 5 minutes to complete.
This questionnaire will provide us with information about your hair loss. Although we aim to make our form simple and comprehensive; on occasion and only when necessary we will contact you for further information.
It is important to be honest and if you are unsure about any of the questions it is always worthwhile speaking to your GP.
• I am a male and 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 doctor has reviewed and confirmed suitability for hair loss medication.
