Hair Loss Treatment Consultation

Personal Information

Please provide your details accurately

Name *

First

Last

Date of birth? *

YYYY

Phone number? *

Address? *

Email? *

What level of male pattern baldness you are currently suffering from? *

How long you are suffering from male pattern baldness? *

FOR LESS THAN ONE MONTH FOR 1-6 MONTHS FOR MORE THAN 6 MONTHS

Did you start losing hair suddenly or gradually? *

IT WAS A GRADUAL LOSS IT STARTED SUDDENLY

If IT STARTED SUDDENLY, please specify:

Do you have any rough, scaly patches or any itchiness on your scalp? *

NO YES

Do you have hair loss on any other part of your body (e.g. Face, eye brows, chest or armpits)? *

NO YES

If YES, IT HAS, please specify:

Do you have any past medical and surgical history that you want to inform our doctor? *

NO YES

If YES, I HAVE, please specify:

Do you have any of the following medical conditions? *

NONE OF THE LISTED MEDICAL CONDITIONS PSORIASIS RHEUMATOID ARTHRITIS SLE/LUPUS AUTOIMMUNE DISEASE OTHER CONNECTIVE TISSUE ILLNESSES

If other, please specify:

Do you have any family history of male pattern baldness? *

NO YES

Do you smoke cigarettes? *

Treatment History & Medications

Please provide details about your treatment history

Please specify your gender? *

MALE FEMALE

Have you used before Finasteride, Fintid, Proscar or Profal before? *

NO NOT ANYMORE YES - LESS THAN 6 MONTHS YES - MORE THAN 6 MONTHS YES - MORE THAN 1 YEAR

If YES, please specify any side effects:

Do you have any past medical or surgical history? If yes please specify below. *

Are you currently taking any prescription, non prescription or illegal drug or herbal medication? and have you recently taken any medication in the last two weeks? please specify. *

NO YES

If YES, I AM, please specify:

Please specify the name of preferred pharmacy where you want to collect your prescription/medications? *

I understand the above mentioned questions and I have answered them truthfully and to the best of my knowledge. *

I CONFIRM

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Review your details and complete payment

Consultation Summary

Hair Loss Treatment Consultation Fee

GP Review + Prescription

€25.00

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