Questions from your Pharmacist

Are you male?*

Yes
No

What is your date of birth?*

This product is only suitable for individuals aged 18 and above.

Have you had this medication before?*

Yes
No

have you taken this medication before box*

Has your hair loss come about gradually or suddenly?*

Gradually
Suddenly

Describe your pattern of hair loss:*

From the crown of my head
From the crown of my head and my temples
From my temples only
In patches all over my head

Are you already taking Propecia (finasteride), Proscar or Avodart (dutasteride) for a condition other than hair loss?*

Yes
No

Do you suffer with allergies?*

Yes
No

Do you suffer from allergies box*

Do you have any kidney or liver problems?*

Yes
No

Do you have any kidney or liver problems box*

Could there be any other explanation for your hair loss including stress, chemotherapy, or poor diet?*

Yes
No

Have you ever been diagnosed with prostate cancer or male breast cancer?*

Yes
No

Are you currently taking any other medication including over the counter medication, herbal medicines or recreational drugs?*

Yes
No

Are you currently taking any other medication including over the counter medication, herbal medicines or recreational drugs box*

Is there any other relevant information our prescriber needs to know in order to prescribe this medication safely to you?*

Yes
No

Is there any other relevant information our prescriber needs to know in order to prescribe this medication safely to you box*

Please consent to the following:*

I have read the patient information leaflet and understand the risks and benefits of taking this medicine.
I have answered all of the above questions accurately and confirm that the medication is for my personal use only.
I understand that finasteride should not be taken by women and in pregnancy, it may harm the unborn foetus. Also, women of childbearing age should not handle crushed or damaged finasteride tablets.
I agree to be treated by the prescribers and healthcare professionals at Linthorpe Pharmacy for my medical condition.
I will contact a medical professional if I have any questions or experience any unusual side effects from my treatment. I understand that I should inform my own GP that I am taking this treatment so they can see a full and accurate picture of my health.
We collect information about your health to make a medical diagnosis and prescribe medicines safely. Under the GDPR this type of data is classed as sensitive and therefore we take further precautions when collecting and processing it. By consenting to this notice, you are giving us permission to process your health data for the purposes of prescribing medicine.
Please be aware that Finasteride can affect the results of a PSA test for prostate cancer. If you ever require a PSA test you must inform the doctor you are taking Finasteride
I understand there have been rare cases of patients developing depression whilst on this medication. If I develop depression, I will stop taking this medicine immediately and inform a healthcare professional.

Consent*

I've read and accept the Terms & Conditions and Privacy Policy.*

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