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Medication Review

Have you experienced any side effects on the medication?

Please choose one or more of the statements that apply to you regarding your hair loss at the moment*

Are you happy to continue with the same treatment regime?

What quantity of medication would you like*

Medical History Review

Has there been any change to your MEDICAL CONDITION(S) or have you developed any new health problems since your last review?

Has there been any changes to your current MEDICATION(S) or have you started on any new medications since your last review?

Has there been any changes to your current ALLERGY status or have you developed any new ALLERGIES?

Pharmacy Options

Declaration

It is important that your General Practitioner knows what medication you are taking. Would you like us to inform them regarding this?