Online Medication Assessment Online Medication Assessment If you have previously ordered Finasteride please contact us to discuss your repeat prescription. Call 0800 832 1899 or email info@hairrepairclinic.co.ukYour Consultation*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. I have read and can confirm my understanding of the aboveWhen did you first notice you were losing hair?Has your hair loss started within weeks or over a longer period of time?Does anyone in your family suffer from hair loss?YesNoI don't knowWhat side of the family? Father's side Mother's side Have you noticed any other changes to the areas where you are losing hair?For example redness, itching, flaking or soreness?YesNoThese symptoms suggest there could be other causes contributing to your hair loss, other than androgenic alopecia, which may improve with other treatments. We'd suggest you see your GP first to consider any other causes before taking this medication. Please tick if you wish to continue Have you been diagnosed with Androgenic Alopecia (Male Pattern Baldness)?Yes, by my GPYes, by a specialistNo - self-diagnosedHave you tried any hair loss treatments before?YesNoPlease listExamples: Finasteride / Propecia, Dutasteride or others including Minoxidil, Regaine Was it effective? Did you have any side effects?Have you had any previous hair loss procedures?YesNoPlease include detailsMedical HistoryDo you have any conditions affecting your liver, kidneys, prostate or urinary system?YesNoPlease provide detailsAre you currently taking any medication, or have you recently finished a course of medication?YesNoPlease list the names and doses of all these medications? What do you use these medications for?Are you allergic to any medicines or other substances?YesNoPlease provide detailsDo you have any skin conditions?YesNoPlease provide detailsPossible Side EffectsDepressionSome people when taking this medication have experienced severe depression. You should stop taking this medication immediately if you notice that your mood is affected and speak to your doctor. You can contact us if you have any questions about this. Please tick if you understand this and wish to continue. Erectile DysfunctionOne of the side effects of finasteride and Propecia, which occurs in around 2% of men, is problems with sexual function, including erectile dysfunction, meaning your symptoms of ED may worsen. Please tick if you understand this and wish to continue. Hair Loss Photos Please include at least two photos as shown Front ViewSide ViewBack ViewTop of Head ViewAdditional AnglesAny additional angles you wish to includeYour DetailsName* First Last Email Address* Mobile Number*Address* Address Line 1 Address Line 2 (Optional) Town/City Postcode Confirmation* I understand the side-effects of the treatment options, their effectiveness and alternative options and am happy to continue with my request. * I confirm and agree that any treatment prescribed for me is for my personal use only.I fully understand the questions asked and have answered honestly and truthfully.Consent* I understand the side-effects of the treatment options, their effectiveness and alternative options and am happy to continue with my request. * I confirm and agree that any treatment prescribed for me is for my personal use only. I agree to the privacy policy. I fully understand the questions asked and have answered honestly and truthfully. I fully understand the questions asked and have answered honestly and truthfully.* I fully understand the side-effects of the treatment options, their effectiveness and alternative options and am happy to continue with my request. * I confirm and agree that any treatment prescribed for me is for my personal use only. Please tick here to signify that you have read, understand and agree to abide by our terms and conditions and privacy and cookie policy. Data CollectionWe treat your information with respect. The submitted data is used by your doctor and your patient coordinator at Hair Repair Clinic. Your data is not shared with any other organisation or third party. I consent to my submitted data being collected and stored Data CollectionWe treat your information with respect. The submitted data is used by your doctor and your patient coordinator at Hair Repair Clinic. Your data is not shared with any other organisation or third party. I consent to my submitted data being collected and stored
