Medical Assessment - Hair Loss

About You

Are you male and aged between 18-65?

We are unable to supply you with Propecia. Please consult your GP.
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Symptoms

Are you suffering from hair loss?

We are unable to supply you with Propecia. Please consult your GP.
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Do you have hair loss in patches, or have an itchy or sore scalp?

We are unable to supply you with Propecia. Please consult your GP.
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Is your hair loss limited to the temple area?

Propecia may still be supplied. Be advised that there is no clinical evidence supporting using Propecia for treatment of hair loss only in the temple area.
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Are you experiencing any inflammation on your scalp?

We are unable to supply you with Propecia. Please consult your GP.
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Do you have sudden unexplained hair loss or complete hair loss?

We are unable to supply you with Propecia. Please consult your GP.
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Could your hair loss be explained by any medication or illness (e.g. chemotherapy or dietary)?

We are unable to supply you with Propecia. Please consult your GP.
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Health

Are you allergic (hypersensitive) to Propecia (finasteride)?

We are unable to supply you with Propecia. Please consult your GP.
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Have you ever been diagnosed with prostate disease or male breast cancer?

We are unable to supply you with Propecia. Please consult your GP.
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Do you have a history of depression or any other mental illness?

We are unable to supply you with Propecia. Please consult your GP.
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Medication

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

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Please continue. You can post messages for the doctor from your My Account area at any time.

Are you taking any of the following medications?

  • Finasteride, Propecia or Proscar for a condition other than hair loss
We are unable to supply you with treatment. Please consult your GP.
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Agreement

Do you understand that if your partner is (or may be) pregnant, they should not handle crushed or broken tablets of finasteride, and that you should always wear a condom for sex?

Propecia can be absorbed through the skin and is excreted in semen. Please confirm that you understand.
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Do you understand that Propecia may take up to 6 months before symptoms start to improve?

Please confirm that you understand.
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Some trials have suggested finasteride use may very slightly increase the risk of developing male breast cancer and prostate cancer. Do you agree to speak immediately to your doctor if:

  • You experience any changes in breast tissue such as pain, lumps or discharge from a nipple
  • You experience any pain, impotence, problems with ejaculation or loss of libido
Please read the product leaflet carefully before deciding to take finasteride
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Are you aware that Propecia may cause erectile dysfunction and you should speak to your GP if this happens?

Please confirm that you understand.
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Do you understand you must stop taking Propecia/Finasteride immediately if you experience any mood alteration including depressed mood, depression or suicidal ideation and should contact a healthcare professional?

Please confirm that you understand.
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Do you agree to the following?

  • You will read the patient information leaflet supplied with your medication
  • You will contact us and inform your GP of your medication 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 must agree to this before continuing. If you need assistance contact customer support.
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