Book Hair Loss

About You

Are you registered with a GP practice in the UK?

Yes No

Do you give us consent to write to your GP for approval of this supply and to share information we hold about you?

(The information entered below in the medical assessment form will be treated with utmost confidentiality whilst being reviewed by the prescriber. It will also provide the prescriber with important information which will help them make an informed decision in deciding if the treatment is considered to be suitable for you).

Yes No

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

Yes No

Are you male and aged between 18 - 65?

Yes No

Symptoms

Are you suffering from hair loss?

Yes No

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

Yes No

Is your hair loss limited to the temple area?

Yes No

Are you experiencing any inflammation on your scalp?

Yes No

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

Yes No

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

Yes No

Health

Are you allergic (hypersensitive) to Propecia (finasteride)?

Yes No

Have you ever been diagnosed with prostate disease or male breast cancer or undergoing PSA (prostate monitoring)?

Yes No

Do you have a history of depression or any other mental illness?

Yes No

Medication

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

Yes No

Agreement

Do you understand that if your partner is (or may be) pregnant, they should not handle crushed or broken tablets of finasteride, and that you should always wear a condom for sex?

Yes No

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

Yes No

Some trials have suggested finasteride use may very slightly increase the risk of developing male breast cancer and prostate cancer. Do you agree to speak immediately to your doctor if:

You experience any changes in breast tissue such as pain, lumps or discharge from a nipple
You experience any pain, impotence, problems with ejaculation or loss of libido

Yes No

Are you aware that Propecia may cause erectile dysfunction and you should speak to your GP if this happens?

Yes No

Do you understand you must stop taking Propecia/Finasteride immediately if you experience any mood alteration including depressed mood, depression or suicidal ideation and should contact a healthcare professional?

Yes No

Do you agree to the following?

I confirm I am over 18 years old.
The medicine ordered is for my sole use only.
I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.
You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
I consent to being contacted by telephone or email should the doctor or pharmacist require further information to assess my order.
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.
You are aware you will be subject to an ID check to verify your ID via LexisNexis Risk Solutions.

Yes No

Hair Loss - Medical Assessment

Are you registered with a GP practice in the UK?

Do you give us consent to write to your GP for approval of this supply and to share information we hold about you?

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

Are you male and aged between 18 - 65?

Are you suffering from hair loss?

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

Is your hair loss limited to the temple area?

Are you experiencing any inflammation on your scalp?

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

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

Are you allergic (hypersensitive) to Propecia (finasteride)?

Have you ever been diagnosed with prostate disease or male breast cancer or undergoing PSA (prostate monitoring)?

Do you have a history of depression or any other mental illness?

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

Are you taking any of the following medications?

Do you understand that if your partner is (or may be) pregnant, they should not handle crushed or broken tablets of finasteride, and that you should always wear a condom for sex?

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

Some trials have suggested finasteride use may very slightly increase the risk of developing male breast cancer and prostate cancer. Do you agree to speak immediately to your doctor if:

Are you aware that Propecia may cause erectile dysfunction and you should speak to your GP if this happens?

Do you understand you must stop taking Propecia/Finasteride immediately if you experience any mood alteration including depressed mood, depression or suicidal ideation and should contact a healthcare professional?

Do you agree to the following?