Assessment Hair Loss
Step
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- Your Details
0%
Your Details
Name
(Required)
First
Last
Gender
(Required)
Male
Female
Address
(Required)
Street Address
Address Line 2
City
Postcode
Email
(Required)
Phone
(Required)
Date of Birth
(Required)
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Year
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Are you breastfeeding or currently pregnant?
(Required)
Yes
No
Medical Questions
The information you provide us is treated with the utmost confidentiality and will be reviewed by a registered doctor. The questions listed are to provide the prescriber with an appropriate level of information to make an informed decision on whether the treatment is suitable or not.
Are you between 18 and 65 years old?
(Required)
Yes
No
Do you have any diagnosed medical conditions?
(Required)
Yes
No
Please provide more information
(Required)
Do you take any medication? This can be prescribed medication or any other over the counter or herbal medicines?
(Required)
Yes
No
Please provide details.
(Required)
Do you suffer from any allergies? This includes any medication or ingredients you may be allergic to?
(Required)
Yes
No
Do you have low blood pressure (below 90/50)?
(Required)
Yes
No
Do you drink alcohol?
(Required)
Yes
No
Have you had any Hair Loss treatment before?
(Required)
Yes
No
Are you suffering from Hair Loss?
(Required)
Yes
No
Do you have a sore, itchy or inflamed scalp?
(Required)
Yes
No
Do you know of any other contributing factors to your hair loss, such as medication, lifestyle, diet or any other conditions?
(Required)
Have you had any unexplained hair loss or complete hair loss or alopecia?
Yes
No
Do you have any allergies (hypersensitivity) to Finasteride or it's ingredients?
Yes
No
Have you ever been diagnosed with one of the following conditions:
(Required)
Prostate problems (prostate enlargement, prostatitis, prostate cancer)
Male breast cancer
Heart Disease (including chest pain, angina, heart attack or any history of cardiovascular event)
High Blood Pressure
Chronic liver disease (including liver cirrhosis)
Pheochromocytoma (cancer of the adrenal glands)
Acute Porphyria (a rare hereditary disease affecting haemoglobin)
None of the above
Unfortunately, we cannot recommend a suitable treatment for you. If you did this in error, you have the choice to change your answer. If you have any questions about this consultation, please email
[email protected]
.
Please provide any additional information that you think we need to know about to safely prescribe your medication (optional)
(Required)
Acknowledgements
By providing your consent, you acknowledge that you understand and agree to the treatment plan and associated terms below.
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?
(Required)
I confirm the above
Yes
No
Can you please confirm that you understand it can take up to 6 months of using Finasteride for symptoms to improve?
(Required)
I confirm the above
Yes
No
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.
(Required)
I confirm the above
Yes
No
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. 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
(Required)
I confirm the above
Yes
No
I confirm I am over 18 years old and 80 years old.
The medicine being requested is to be used solely for my own use.
I will read the patient information leaflet supplied with the medication.
I take responsibility to inform my own regular GP of the online consultation, any medication issued or any changes in my symptoms or medical conditions.
I agree to contact my GP if there is no relief of symptoms after 14 days or if my symptoms are worsening
I have answered all the questions truthfully and accurately.
I understand that the final decision to issue the medication lies with the prescriber. At this stage, my request still needs to be reviewed and approved by the prescriber, therefore there is no guarantee that a prescription will be issued.
I confirm I have the capacity to make decisions about my own health.
I have read and agree to the terms and conditions of Newtons Chemist
Confirmation
(Required)
I confirm the above
Consent
(Required)
I confirm the details are true and I consent to processing my health data.
Please confirm you agree the following:
(Required)
Do you consent to us requesting further information on your medical history from your GP? This is to ensure that any treatment we recommend for you is appropriate and safe. For full details, please click the
"Need help?" link below. Any references to "we" or "us" refers to ABSM Healthcare Limited.
I confirm the above
Consent
(Required)
Do you consent to us accessing your NHS Summary Care Record (the medical details held by your GP) or requesting further information on your medical history from your GP?
One or more of your answers means this online service is not suitable for you. You will not be able to complete this form. Please contact your GP or another healthcare professional.
