Medical Assessment for Hair Loss (Men)

Patient Information

Are you 18-65 years old?

Are you and your partner planning to get pregnant?

Is your scalp healthy (no inflammation, redness, scabs, abnormal itching, excessive flaking)?

Medical History

Do you have a history of any of the following?

• Any type of cancer
• Heart disease
• Hypertension
• Liver disease
• Bladder and/or kidney disease
• Disease of the prostate

Could your hair loss be explained by any medication, dietary matter, or illness?

Are you taking recreational drugs?

Do you have any allergies to minoxidil, finasteride, dutasteride, or other medications of the same type?

Consent

Do you agree to the following?

• You will take the medicine as directed by your doctor or as indicated in the information leaflet supplied with the medication
• You will contact us and inform your doctor if you experience any side effects of treatment, if you start new medication, or if your medical conditions change during treatment
• The treatment is solely for your own use
• You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly and that incorrect information can be hazardous to your health
• You understand that whilst decisions relating to your treatment are made jointly between you and the prescriber, the final decision to issue a prescription will always be with the prescriber