Are you male?

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 hair loss?

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 experiencing sudden or complete hair loss?

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.

Is your hair loss limited to the temple area?

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.

Is your hair loss patchy and in random places?

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 suffering from any inflammation on your scalp?

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 finasteride (Propecia) or any of the ingredients in this medicine (e.g. lactose)?

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 currently taking finasteride, dutasteride, Propecia or Proscar for a condition other than hair loss?

Yes No

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 other medication?

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.

Have you ever been diagnosed with prostate disease, prostatic hyperplasia, prostate cancer or male breast cancer?

Yes No

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.

Can there be any other reason (medication or illness) that is causing your hair loss, including chemotherapy or poor diet?

Yes No

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 aware that Finasteride has been associated with side effects of sexual dysfunction (including decreased libido and sexual dysfunction), and risks of psychiatric side effects (depression, suicidal thoughts), and that you should consult your doctor if you have a history of or suspect you are suffering with any of these issues?

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 aware of the following?

Yes No

women should not handle crushed or broken tablets of finasteride (Propecia) if they are pregnant or may become pregnant;
finasteride (Propecia) is excreted in semen therefore use of a condom is recommended if your partner is pregnant or may become pregnant to avoid any birth problems;
after starting this medication it may take up to 6 months before symptoms start to improve, if you stop taking finasteride (Propecia) you are likely to lose the hair you have gained within 9 to 12 months;
you should promptly report any changes in your breast tissue such as lumps, pain, enlargement or nipple discharge;
mood alterations such as depression and suicidal thoughts have been reported in patients treated with finasteride (Propecia). If you experience these symptoms, stop taking finasteride (Propecia) and contact your doctor for advice as soon as possible;

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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Medical Assessment