Hair Loss Consultation

Are you Male and aged 18 years and older? *

Yes No

Have you taken Finasteride for hair loss before? *

Yes No

Has your hair loss just come on suddenly and unexpectedly? *

Yes No

Please provide more details

Is your hair loss in patches? *

Yes No

Does your hair loss cover just the temple area? *

Yes No

Can your hair loss be explained by something else such as medication, illness (eg Chemotherapy) or even stress? *

Yes No

Are you taking any of the following medications for the treatment of prostate enlargement, usually referred to as benign prostate hyperplasia? *

Finasteride (For something else other than hair loss) Tamsulosin Alfusozin Doxasozin None of the Above

Do you currently have or have ever had any of the following: *

A history of depression or any other mental health conditions? Current or previous diagnoses of prostate or male breast cancer? History of sensitivity (allergy) to finasteride (Propecia)? History of any inflammation on the scalp? None of the Above

Have you ever had an allergic reaction to Finasteride? Or have any other allergies we should be aware of? *

Yes No

Please provide more details on all allergies you have

Are you currently taking or have recently finished taking (in the last month) any medication, whether prescribed or non-prescribed including over-the-counter, herbal, or recreational drugs? *

Yes No

Please provide an update list of all medications whether prescribed or non-prescribed including over-the-counter, herbal, or recreational drugs that you are taking or have recently stopped taking

Do you or have you ever suffered from any liver, kidney or prostate problems? *

Yes No

Please provide more details

Is there any other medical or non-medical information we should be aware of? *

Yes No

Please provide more details

Do you suffer from depression or any other mental health conditions? *

Yes No

Please provide more details

Would you like us to inform your GP of any treatment you receive from us? *

We can still prescribe this medication to you if you select No, however, we do advise you to inform your GP of any treatment you receive from us to make sure your health records are up to date

Yes No

Before you continue

Please read the following statements:

I have answered all these questions in full accurately and truthfully and I will contact you if there is any change to the above questions. I understand any incorrect information may be detrimental to my health
I understand that if I develop any symptoms of depression or other mental health conditions whilst on this medication, I will stop taking the treatment immediately and will contact a Doctor
I am requesting treatment for myself and any prescribed treatment will be for my sole use
The information provided will be collected and processed in accordance with GDPR regulations. I agree for my information to be processed by Pharmacy in order to provide my treatment and that the prescribers will ultimately have the final decision whether to prescribe any medication
If I suffer any side effects from my treatment I will contact Pharmacy and or my GP immediately
I will read the patient information leaflet before taking the medication and I will contact a health care professional if I have any questions relating to my treatment or the information contained within it
I should inform my GP that I am taking this medication
I understand if I ever have a PSA test, which is a test for Prostate cancer, I must inform the person conducting the test I am taking Finasteride as it can affect the results of the test
I understand it may take up to 6 months before I notice any reduction in hair loss and that should I stop taking Finasteride for whatever reason the effects may be reversed after 6 -12 months
I understand women of child bearing age and pregnant women should NOT handle crushed or damaged Finasteride tablets

I agree to all of the above statements