Hair Loss Consultation

Your complete and honest disclosure will enable our healthcare professionals to make informed decisions and provide you with the best possible care. Please provide accurate and detailed information when needed in the consultation questionnaire below.

Do you need help completing this questionnaire? Email us or Call us during our working hours (9am - 5pm / Monday - Friday)

Name *

First

Last

Phone

Email *

your provide medication

GDPR Agreement *

I consent to having this website store my submitted information so they can respond to my inquiry.

What is your gender *

Male
Female
Other

What is your date of birth? *

Have you been diagnosed with any medical conditions? *

Please provide more information. *

Please use a comma to separate each condition

Have you ever been diagnosed with a mental health illness or depression? *

Please provide more information. *

Please use a comma to separate each condition

Do you suffer from any allergies? *

Please provide more information. *

Please use a comma to separate each allergy

Have you had any Hair Loss treatment before? *

Please state which medication you have had *

Please use a comma to separate each medication

Are you suffering from Hair Loss? *

Where is the hair loss? Please state if it is patchy hair loss / crown or temple hair loss. *

Are you male and are you between 18-75 years of age? *

Do you have a sore, itchy or inflamed scalp? *

Do you experience unexplained hair loss or complete hair loss or alopecia? *

Do you know of any other contributing factors to your hair loss, such as medication, lifestyle, diet or any other conditions? *

Please provide more information *

Do you have any allergies (hypersensitivity) to Finasteride? *

Have you ever had a diagnosis of prostate disease or male breast cancer? *

Are you currently taking any over the counter, prescription, or recreational drugs? *

Please provide more information *

Can you please confirm that if your partner is pregnant, they should not handle crushed or broken tablets of Finasteride and that you should always wear a condom for sex? *

Confirm
Decline

Can you please confirm that you understand it can take up to 6 months of using Finasteride for symptoms to improve? *

Confirm
Decline

Please confirm that you will 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 *

Confirm
Decline

In some trials of Finasteride, it has been suggested that there is very slight increase in the risk of developing male breast cancer and prostate cancer.

Do you understand that for some patients, Finasteride can affect their mental health? Please ensure you let us know if this happens or speak with your GP. *

Confirm
Decline

Please confirm the below *

Confirm
Decline

* I agree to ordering the lowest strength, if this is the first time I am taking this medication.
* I confirm I am over 18 years old.
* The medicine being requested is for my use only.
* I will read the patient information leaflet supplied with the medicine, specifically the side effects and dosages.
* I take responsibility to inform my own regular doctor of the online consultation or any changes in my circumstances.
* I have answered all the questions truthfully.
* I understand my request still needs to be reviewed and approved by the prescriber; until they approve, my request is not guaranteed at this stage.
* I confirm I have the capacity to make decisions about my own health.
* I agree to the The Pill Box terms and conditions.

❗

Please confirm the details provided are accurate and truthful. Your request cannot be reviewed until confirmation is received.

Would you like us to inform your doctor of the treatment you chose to order today? *

To continue, please provide your GP's surgery address below. *

Hair Loss Consultation Form

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