Hair Loss (Finasteride) Form

Personal Details

What Sex were you assigned at birth? *MaleFemale

Please visit your GP at the earliest convenience. We are unable to supply you with medication at this time

What is your Date of Birth?

Month

Day

Year

Symptoms

Do you suffer from hair loss? *YesNo

Please visit your GP at the earliest convenience. We are unable to supply you with medication at this time

Could your hair loss be explained by anything such as medical history, drug history or diet? *

Do you have any of the below affecting the scalp? *RednessBlisteringDrynessNone of the above

Please visit your GP at the earliest convenience. We are unable to supply you with medication at this time

Has your hair loss been sudden? *YesNo

Please visit your GP at the earliest convenience. We are unable to supply you with medication at this time

Your Health

Have you ever been diagnosed with the following?

I have previously been diagnosed with breast cancer, prostate cancer, and I am currently undergoing PSA (prostate monitoring).
I have uncontrolled low or high blood pressure.
I am experiencing, or have previously experienced, depression, anxiety, or panic disorders.
I am trying to conceive or planning to start a family soon.

Select Option *YesNo

Please visit your GP at the earliest convenience. We are unable to supply you with medication at this time

Have you used finasteride in the past? *YesNo

Have you had a previous allergic reaction to finasteride, Propecia, Minoxidil, Lactose or Regaine. *YesNo

Please visit your GP at the earliest convenience. We are unable to supply you with medication at this time

Please provide details of any underlying health conditions? *

Have you previously been diagnosed with breast cancer, prostate cancer or are you currently undergoing PSA (prostate monitoring)? *YesNo

Please visit your GP at the earliest convenience. We are unable to supply you with medication at this time

Medication History

Which medications are you currently taking? *

Agreement

Please agree or disagree to the following :

Do you understand that if you are prescribed finasteride and your partner is (or may be) pregnant, they should not handle crushed or broken tablets and that you should always wear a condom during sex?
I will contact my GP or pharmacy if I suffer from any adverse effects to the medication
I have answered all the questions and statements truthfully and understand if I have falsified information I may be putting my own health in jeopardy
I understand that the prescriber will review my information and based on my answers will decide whether or not the medication is safe for me
I understand that if my GP is unaware of my hair loss, I will inform them at the earliest convenience in order to rule out any serious underlying health conditions.
I understand that the pharmacist may require access to my Summary Care Records (SCR) to double-check any contraindicating medications I may be on. In this case, I consent to the pharmacist and solely the pharmacist to view my SCR.This question is required.

I acceptI don't accept

Would you like to notify your GP of this treatment? *YesNo

Please provide us with the details of your GP surgery

Address

City

State/Province

Country

Medicine *Continue

Select Medicine *Finasteride

Finasteride (mg) *

Finasteride (1mg) Pack size *

Finasteride 1mg

Finasteride (5mg) Pack size *

Finasteride 5mg

Proceed to Checkout *Continue to Checkout

Name *

Email Address *

Phone *

Shipping Address

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Credit / Debit Card *