Hair Loss

When did you first begin losing your hair?

Did your hair loss happen suddenly and quickly?

Have you or are you currently experiencing any of the following symptoms on your scalp area?
- Any unexplained spots or lesions
- Any flaking
- Any swelling
- Any pain or inflammation

Is your hair loss occurring in random patches over your scalp?

Have you ever previously used treatment for hair loss?

Are you currently using any other products or treatments for hair loss?

Have you ever been diagnosed with any other medical conditions?
This can include:

-Immune system conditions such as HIV
-Liver or kidney issues

Do you suffer with any allergies?

Do you currently take any medication? This includes herbal remedies and over the counter medication.

Is there any other information you would like to share with our prescribing team?

We strongly recommend that you inform your GP of any treatment you receive. Would you like us to do this on your behalf?

Do you agree to the following?
- I am between the ages of 18 and 65
- This treatment is for my use only
- I have the capacity to make decisions about my own healthcare
- I have understood all the questions and have answered this consultation truthfully and completely
- I understand the prescriber will use my answers and base their prescribing decisions accordingly, and that providing incorrect information could be harmful to my health
- I will read the patient information leaflet supplied with this medication
- I will contact we prescribe and inform my GP if I experience any side effects from this treatment or if there are any changes to my health
- I have read, understood and agree with our Terms and Conditions