Get a Prescription for Facial Hair

- Step 1 of 6

Name *

First

Last

Date of Birth *

Email *

Address *

Select Pharmacy to where prescriptions should be sent. Select "other" if you can't find your pharmacy *

1. Please confirm your birth gender is female *

Yes- I confirm my birth gender is female
No

Please share more information with us *

2. Please confirm that you are over 18 years old *

Yes- I confirm that I am over 18 years old
No- I am under 18 years old

3. Do you have facial hair that you would like to get rid of? *

Yes- I have unwanted facial hair
No

Please share more information with us *

4. Are you pregnant? *

Yes
No

5. Are you breastfeeding? *

Yes
No

6. Please confirm if you are taking any of the following medications *

Cyclosporine
long term oral steroids
Minoxidil
Phenobarbitone
Phenytoin
Danazol
None of the above

7. Do you have any of the following conditions *

Cushings Syndrome
long term oral steroids
Congenital adrenal hyperplasia
Tumours of the ovary and adrenal glands
None of the above

8. Please confirm that you understand the statement below: Medical problems can lead to excess facial hair. If you are also experiencing irregular periods, acne, weight gain, new stretch marks and sudden rapid hair growth we advise that you speak with a Doctor around these symptoms. *

Yes- I confirm I understand
No

9. Please confirm the following information is understood about the medication Vaniqa: This is not a facial removal cream and is used to reduce the growth of hair on the face. It usually takes around 4 weeks to see any difference, but some users have found it can take up to 4 months. If you feel this medication is not working for you, please speak with a Doctor. This is a long term treatment, and hair will return to the face if you stop using the treatment. You should only use the cream on your face and around your chin area, and nowhere else on your body. *

Yes- I confirm I understand
No

10. Are you using Vaniqa at the moment? *

Yes
No

11. Have you had rapid unexpected hair growth in the last few months? *

Yes
No

12. Please share the area of your body where you have the unwanted hair *

Face
Chest
Back
Neck
Other

Please share more information with us *

13. Would you describe the excess hair as thin or thick? *

Thin
Thick

14. Are you having regular periods? *

Yes
No

Please share more information with us *

15. Are you currently using hormonal contraception? *

Yes
No

Please share more information with us *

16. Are you currently using hormone replacement therapy? *

Yes
No

Please share more information with us *

17. Have you ever been diagnosed with any kidney conditions? *

Yes
No

Please share more information with us *

18. Have you ever been diagnosed with any liver conditions? *

Yes
No

Please share more information with us *

19. Have you ever been diagnosed with PCOS (polycystic ovary syndrome) *

Yes
No

Please share more information with us *

20. Do you have any other medication conditions? *

Yes
No

Please share more information with us *

21. Do you take steroid medication? *

Yes
No

Please share more information with us *

22. Do you take any prescription medications? *

Yes
No

Please share more information with us *

23. Are you taking any non-prescribed medications (over to counter, herbal remedies etc) *

Yes
No

Please share more information with us *

24. Do you have any allergies? *

Yes
No

Please share more information with us *

25. Please share your height and weight *

26. Please confirm you have answered all questions with honesty, and the completion of this questionnaire is for your own personal use of the prescribed treatment. *

Yes
No

Please share more information with us *

Price

Total Amount: 25 €

Pay with a Debit or Credit Card *

Card

Name on Card