Are you female?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you suffer from unwanted facial hair?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you pregnant or breastfeeding or may become pregnant or start breastfeeding whilst taking this medication?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you allergic to eflornithine or to any of the ingredients in this cream?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you suffer from any of the following?

Yes No

polycystic ovary syndrome (PCOS);
Cushing's syndrome;
congenital adrenal hyperplasia;
androgen-secreting tumour of the ovaries or adrenal gland;
kidney problems;
liver problems;
any other chronic condition that we should know about;

Can you please provide more details?

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you taking any of the following medication?

Yes No

cyclosporine;
glucocorticoids (to treat rheumatoid arthritis or allergy);
minoxidil;
phenobarbitone or phenytoin (for epilepsy);
hormone replacing therapy ;

Please provide the name, dosage and the reason why you are taking that medication or medications.

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you taking any other medication not mentioned above?

Yes No

Please provide the name, dosage and the reason why you are taking that medication or medications.

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you understand and agree to the following?

Yes No

Vaniqa is used to slow down hair growth and is not a hair-remover;
Vaniqa is for long-term use and may take up to 4 months to work;
if irritation occurs or if no benefits are seen after 4 months then use of this treatment should be discontinued;
Vaniqa should only be used sparingly on the affected area of the face twice daily and must not be used on other parts of the body;

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you agree to the following?

Yes No

you have answered truthfully to all the questions and you are aware that any incorrect information you provided can present a potential danger to your health;
you will inform your doctor about any unusual side effects;
the treatment is solely for your own use;
you will read the patient information leaflet supplied with your medication;
you will not exceed the maximum daily dose of this medication ;

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

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I confirm that I am over 18 and I agree to the Terms and Conditions and the Privacy Policy.

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Medical Assessment