Name *

First Name

Last Name

What was your gender at birth?

Male

Female

Please read the statement and accept if you meet all criteria. *

- I am male and over 18 years old. - I currently live in the UK. - I am using this service of my own free will. - I shall be the sole user of any medication offered to me through this service and prescribed by The Health Hub Group independent prescribers. - I agree to the terms and conditions, terms of use and privacy policy. - I confirm all answers will be provided honestly and truthfully.

agree to continue

Please select the option that best describes your hair loss.

mild

temples/crown

thinning

all over

extensive

Has your hair loss developed suddenly?

No

Yes

Have you been previously diagnosed with male pattern baldness?

Yes by a GP

Yes by a Hair Specialist

Yes by a Hair Clinic

No, I am self-diagnosed

Could your hair loss be caused by other medication or illness (chemotherapy, thyroid disorder)?

Yes

No

Have you ever taken any of the below medicines before?

Finasteride or Propecia

Minoxidil or Regaine

Topical Finasteride Minoxidil Combination

None

Did you have side effects when using your medicine?

Yes - Finasteride

Yes - Minoxidil

No

Do you suffer from any of the following?

Please note, your answers will be cross checked against NHS records. To avoid unnecessary delays or cancellations with your order, please ensure you select all conditions as appropriate

Rheumatoid Arthritis, Systemic Lupus or on Methotrexate

Scalp Disorders (including Scalp Psoriasis, Eczema, Dermatitis or Infection)

Severe Kidney Disease/Dialysis

Liver Disease or Abnormal Liver Function

Prostate Disease, Male Breast Cancer or Testicular Cancer

High Blood Pressure

Significant Depression or Anxiety

Other Mental Health Disorders

Sexual Dysfunction

Cardiovascular Disease (incl. Heart Attack, Rhythm, Valve Disorder or Stroke)

Phaeochromoctyoma

Diagnosed Lactose Allergy

Other

None

Please read the statement and accept if you agree

- I will read the patient information leaflet supplied with all my medicine(s) before taking or using any of the medication. - I will stop Finasteride one months prior to trying to conceive/start a family and hold off restarting until my partner’s pregnancy is into the second trimester. - I am aware that Finasteride may cause mood changes and if this happens that I will contact my GP immediately and I understand there is a possibility that side effects may persist after stopping the medication. - I will let my doctor know I am taking Finasteride if I have a PSA test as Finasteride can affect PSA levels - 0.1% Finasteride / 5% Minoxidil, 3%, 6% and oral minoxidil are unlicensed products produced by a specials manufacturer where the medicine does not currently have a valid UK marketing authorisation. - I will seek immediate medical attention if I experience any adverse events and report them to Yellowcard. - I will seek a medical appointment or consultation and stop taking Finasteride if I experience any change in my mental state or suicidal thoughts. - I will inform my GP or any other prescribing physician if I am taking Finasteride or Minoxidil. I will stop minoxidil straight away if I get any symptoms of light-headedness or dizziness. I will stop the medication if recommended to do so on medical grounds by them. - I have capacity to make decisions about my own care. - I consent to receive marketing communications via Email, SMS, and Postal Mail. - I consent for my information to be shared with my registered GP and for The Health Hub Group to contact me directly should they require any further information. - I give permission to The Health Hub Group's independent prescribers to view my Summary Care Record (NHS Record) if, for clinical reasons, they deem it necessary.

I accept