Hair Loss Questions

About you and your symptoms

Are you aged 18 – 65?

Are you suffering from hair loss?

Do you have hair loss in patches or have an itchy 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, chemotherapy or dietary?

Do you or have you suffered from any heart problems stroke, angina or any other heart related problems ?

Are you taking any medication that has been prescribed by your Gp/Doctor or Hospital ?

Do you give consent for us to contact you GP if required? (we need this to process any order for medication)

Your Current Health

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

Are you taking any of the following medications?

  • Finasteride, Propecia or Proscar for a condition other than hair loss

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


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:

  • 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

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 develop depression and should contact a healthcare professional?

Do you agree to the following statements?

  • You must read the patient information leaflet supplied with your medication
  • You must 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.
  • The treatment is solely for your own use only.
  • You have answered all the questions in this short medical assessment accurately and truthfully to the best of your knowledge. You understand our doctor take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.
all of our tests and treatments are price competative

You need to complete our short medical questionnaire so we can ensure the treatment you have selected is safe for you to use

all of our tests and treatments are price competative

Need Help?

If you need help with this medical questionnnaire call us on 07549286701

quality products assured across youth revisited

Quality products

all of our tests and treatments are price competative

Affordable prices

all of our pharmacies and and treatments purchased are from well known and trusted UK pharmacies

UK pharmacy

all of our tests and any other products purchased will be dispatched for a next day service

Express next day delivery

If you have any further questions about any of our products please feel free to contact us and we will do our best to help you.
Once you have your prescription we will be able to process your order through our trusted UK Pharmacy.