Your Consultation – mypharmacystop.com

What is your gender?

Do you need help completing this questionnaire?

Yes

Do you believe that you have the capacity to make decisions about your own healthcare?

Yes

Have you been diagnosed with any medical conditions?

Yes

Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.

Yes

Do you suffer from any allergies?

Yes

Is there anything else you would like to include to allow our prescriber to prescribe responsibly?

Yes

Are you a male and aged between 18-45 years old?

Yes

Are you suffering from hair loss?

Yes

Do you have hair loss in patches, or have an itchy or sore scalp?

Yes

Is you hair loss limited to the temple area?

Yes

Are you experiencing any scalp inflammation?

Yes

Do you have sudden unexplained hair loss or complete hair loss?

Yes

Could your hair loss be explained by any medication or illness (i.e chemotherapy or dietary)?

Yes

Are you allergic (hypersensitive) to Propecia or Finasteride?

Yes

Are you currently taking Finasteride for any condition other than hair loss?

Yes

Do you understand that:

Any women of child-bearing age should not handle crushed or damaged Finasteride tablets?
Men trying to conceive must stop taking Finasteride?

Confirm

Do you understand that Finasteride may take up to 6 months before symptoms start to improve?

Confirm

Have you ever been diagnosed with prostate disease or male breast cancer?

Yes

Do you agree to the following?

You will contact us and inform your GP of your medication if you experience any side effects of treatment, If you start a new medicine or if your medical conditions change during treatment.
You will contact us and inform your GP of your medication if you experience any side effects of treatment
You will read the patient information leaflet supplied with your medication
You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.

Confirm

Would you like us to notify your GP of the treatment you chose to order today?

Yes

Do you agree to the following:

You understand the prescriber will take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
You are aware you will be subject to a soft check to validate your identity via Experian
You will read the Patient Information Leaflet supplied with your medication
You agree to Cloud Pharmacy terms and conditions and privacy policy.
The treatment is solely for your own use
You have answered all the above questions accurately and truthfully
You will inform your GP of this purchase if appropriate

I confirm that I understand and agree to the above

Hair Loss