Hairloss prescription questionnaire

In order for our GP's to review your questionnaire and prescribe your chosen medication, we will need to know about your medical history and symptoms. This is important for our clinical team to assess the suitability of the treatment for you. We need you to answer all the questions asked with honesty. If you are unable to understand or confidently answer a question, please check with your GP or book an appointment with one of our Doctors.

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: Are you a new or existing customer? *

New
Existing

2: Please describe your hair loss *

Temples only (front receding)
Temples and Crown
Moderate
Extensive
Complete
In patches

Due to the nature of your hair loss, it is uncertain whether the treatment we offer will provide any effect. *

Please confirm you understand this

Is your scalp currently itchy, rough or showing scaling areas? *

please share more information with us *

Can you please share more information on the patches of hair loss you are experiencing? *

3: Have you experiences hair loss anywhere else on your body? *

Please share more information with us *

4: Please share when you started losing your hair *

Less than a month ago
More than a month ago

5: How quickly did your hair loss begin? *

Quickly
Slowly over time

Please share more information with us *

6: Are you using Finasteride or Propecia for hair loss at the moment? *

How long have you been taking it? *

Less than 6 months
More than 6 months

Are you finding this treatment effective? *

Yes
No
I have only been using it 6 months and have not seen any results but would like to continue

Are you currently experiencing any side effects? *

Please share more information with us *

Is your partner currently pregnant or are you trying to get pregnant? *

My partner is pregnant
We are currently trying for a baby
Not applicable

Is your partner currently pregnant or are you trying to get pregnant? *

My partner is pregnant
We are currently trying for a baby
Not applicable

If you partner is currently pregnant it is important that you use protection (condoms) while taking finasteride or Propecia to prevent any danger or harm to the baby. *

Please confirm you understand this

Are you currently taking medication for a prostate condition? *

Please share more information with us *

7: Are you currently taking any prescription medications, over-the-counter medications or any alternative medicines/recreational drugs? – or homeopathic treatment? *

Please share more information with us *

8: Please confirm if you have any of the following conditions? *

Cancer
Liver Condition
Depression
Skin Condition
Kidney/Urinary condition
Hereditary problems of Lapp lactase deficiency, glucosegalactose malabsorption or galactose intolerance
None

9: Do you have any of the following connective tissue illness? *

Psoriasis
Rheumatoid arthritis
Sistemic Lupus Erythmatosis
Autoimmune disease
Kidney/Urinary condition
Other
None

10: Do you smoke? *

11: Does anyone on your family (mother’s or father’s side) have male pattern baldness? *

12: Can you please confirm if you have had any other significant medical illness, condition, hospital stays or past surgical procedures? *

Please share more information with us *

13: Can you confirm if you have allergies *

Please share more information with us *

14: Please confirm you have understood our policies of hair loss treatment and confirm: You will be taking the treatment for at least 3-6 months before any significant changes and benefit will be shown. Ceasing treatment will have reverse any progress and your hair loss will restart. *

True
False

15: You will also need to confirm that you understand these medications can affect prostate blood test results. If you need to take a prostate blood test at any point, you need to inform your Doctor that you are currently taking finasteride or Propecia. *

I understand

16: Before we proceed, would you like to share any further information? *

Please share more information with us *

17: It is ideal that your GP knows all medications that you are using. Would you like us to share this information with your GP? *

Please share more information with us *

18: Lastly, can you please confirm that you have understood all the questions asked, and answered them honestly. This is treatment is only for your own self use. You also understand the side effects, other options available and that you can speak to one of our GP’s if you need any further information. *

Confirm

Price

Total Amount: 25 €

Pay with a Debit or Credit Card *

Card

Name on Card

Get a Prescription for Hair Loss