Prescription Form | The Hair Loss Shop

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THE HAIRLOSS SHOP PRESCRIPTION FORM

When ordering certain hair loss medication from The Hairloss Shop we may require you to fill out a prescription form. Our Minoxidil and Finasteride solutions will require a prescription to be issued by our in-house pharmacist for us to dispatch your order.

Please fill out the following details giving us an honest outline of your current health in order for us to prescribe your medication.

PLEASE NOTE THAT YOU WILL BE REQUIRED TO FILL A PRESCRIPTION EACH TIME YOU ORDER.

Please confirm the following: *I am over the age of 18I will be the sole & only user of any prescribed medicationI confirm that all answers will be true and completed by myself

First Name *

Last Name *

Email Address *

Phone *

Street Address *

Apartment, suite, etc

City

County

Postal Code *

Country

What was your gender at birth? *MaleFemale

What is your date of birth? *

How is your general health? *

Have you ever had medication relating to your prostate? / had your PSA levels checked? *YesNo

Are you taking any other medication? *YesNo

If yes please provide additional information.

Do you suffer from high or low blood pressure *YesNo

If yes please explain

Do you suffer from any allergies? *YesNo

Please describe your allergies

Would you like us to inform your doctor of any treatments that are prescribed to you by The HairLoss Shop?? *YesNo

Please provide your doctors Name and Address

Do you agree to read the patient leaflet before taking any medication prescribed to you?YesNo

How long have you suffered from hair loss? *

Was the onset of hair loss sudden or gradual? *

Any lifestyle circumstances that may have led to hair loss (eg. Physical or Emotional Stress, Weight Loss, Stress)?

Have you tried other hair loss remedies? *YesNo

Please describe other remedies explored.

Were any results seen?YesNo

Please explain the results you noticed

Did you notice any side effects from your treatment?YesNo

Please describe the side effects experienced

Are you currently being treated or tested for any cancer treatments? *YesNo

Please give more information

How long ago were you last treated or tested

GDPR *Yes, I agree with the privacy policy and terms and conditions.

Hair at Home Re-Growth Specialists, supported by professional hair transplant surgeons and consultants.

hello@thehairloss.shop

0203 819 8805

Pharmacy Reg No: 1033576

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Prescription Form

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