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Medication Review

Have you experienced any side effects on the medication?

Yes

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

My hair loss has stopped

My hair loss has slowed down

There has been no change in my hair loss

I'm definitely noticing regrowth and thickening of my hair

I have had some minor regrowth and thickening of my hair

I have not experienced any regrowth or thickening of my hair

Are you happy to continue with the same treatment regime?

Yes

What quantity of medication would you like*

I would like 1 month supply (combined foam and solution ONLY)

I would like 3 months supply

I am stable on medication and would prefer 6 months supply

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?

Yes

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

Yes

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

Yes

Pharmacy Options

YES, I'll go with Hair Doctors Trusted Pharmacy

NO, I'll go with my own

Questions from our Compounding Pharmacy

Have you taken this medication before?

Yes

Do you take any other medications (including Vitamins/Supplements)

Yes

Do you have any medical conditions?

Yes

Do you have any allergies?

Yes

Are you Pregnant/Breastfeeding?

Yes

Declaration

I confirm that the medication issued will only be used by myself and as instructed

I confirm that all the information I have provided on the Medication Request Form is true and accurate, and that I have not omitted any relevant information:

I have read all the Consumer Medication Information (CMI) leaflets regarding the medication sent to me before, and confirm I do not have any contraindications or allergies to them

I understand that Finasteride can be harmful to women who are pregnant or trying to conceive and will ensure my oral or topical medication will not be handled by them

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

Yes