Male Patients Form 3

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Male - Hair Loss Treatment

Put your details

Pharmacy Name*

Pharmacy Location*

Pharmacy EirCode*

Please identify the level of Male Pattern Baldness which you are currently experiencing?.

For how long has your male pattern balding been an issue to you?

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

Was your hair loss sudden or gradual?

IT WAS A GRADUAL LOSS If IT STARTED SUDDENLY, please specify:

Have you noticed any itchy, rough or scaly patches on your scalp underneath your hair?

NO YES

Have you noticed any hair loss which has occurred on any other body locations (e.g. eye brows, genital or armpit areas)?

NO If YES, IT HAS, please specify:

Apart from conditions already mentioned in this form, do you suffer from any other medical conditions or have you had any surgical procedures in the past that you feel the Doctors should be aware of?

NO If YES, I HAVE, please specify:

Have you been diagnosed or received treatment for any of the following conditions:

NONE OF THE LISTED MEDICAL CONDITIONS PSORIASIS RHEUMATOID ARTHRITIS SYSTEMIC LUPUS ERYTHEMATOSIS (SLE OR LUPUS) AUTOIMMUNE DISEASE OTHER CONNECTIVE TISSUE ILLNESSES If other, please specify:

Is there any family history (either on your mother or fathers side) of male pattern baldness?

YES NO

Are you a smoker?

Gender

MALE

Have you ever been prescribed or take Finasteride / Fintid / Proscar or Profal?

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:

Within the last 2 months have you or are you taking any prescription, non-prescription, recreational/illegal drugs or herbal remedies that you have not already mentioned?

No If YES, I AM, please specify:

What age are you?

The prescription is digitally sent to a pharmacy of your choosing (place Pharmacy details below eg: Stacks Pharmacy / Bettystown)

Within the last 2 months have you or are you taking any prescription, non-prescription, recreational/illegal drugs or herbal remedies that you have not already mentioned?

I CONFIRM

Complete the prescription form below. If the doctor determines that an prescription is not appropriate for your case, you will be refunded.

EXPRESS SickCert: Prescription within 24hrs sent via email. 29.99 EUR

*This will be reviewed and signed by an Irish doctor and is emailed to you within 24 hours.

RECOMMENDED: Prescription will be prioritised in the queue and sent via email. 24.99 EUR

*This will be reviewed and signed by an Irish doctor, sent via email and your request will be at the top of the request queue.

EMAIL: Prescription will be sent via email within 2-3 working days 19.99 EUR

*This will be reviewed and signed by an Irish doctor and sent via email, usually delivered within 2-3 working days.

I confirm that I am not seriously unwell and I do NOT have any of the following symptoms: chest pain, shortness of breath, unable to swallow fluids or saliva, weakness or numbness down one side of my face or limbs or body, slurred speech. I confirm I do not think I need to see a GP. I confirm that this is not a replacement for a doctor's visit. I have read, understood and agree with the information in the terms of service and consent to the use of information in accordance with the (privacy policy).

I CONFIRM I DO NOT CONFIRM

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Male Patients Form 3

Male - Hair Loss Treatment

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