top of page
Date of birth
Gender
Male
Female
Other
Do you smoke?
Yes
No
Ex-Smoker
Do you take any of the following medications?
Do you have any allergies?
Not Sure
No
Yes
Do you suffer high blood pressure?
Not Sure
No
Yes
Do you have any history of symptoms of anxiety or depression?
Not Sure
No
Yes
How long have you been suffering from hair loss?
0-3 months
3-6months
1 year - 5 years
More than 5years
Are you or have you been treated or tested for any cancers or any changes in breast tissue?
No
Yes
Are you currently using any hair loss treatments or medication for hair loss?
No
Yes
Are you currently pregnant or breast feeding?
No
Yes
Are you considering any family planning in the next six months?
No
Yes
What active molecules are you interested in?

Do you agree to the following?


  • You have answered all of the above questions accurately and truthfully. You understand our prescriber(s) will prescribe medication based on your responses and a remote consultation. Any incorrect responses or deliberate acts to misinform may be hazardous to your health.

  • Our prescriber MAY request a video consultation after the initial phone consultation.

  • You agree to the terms and conditions, privacy policy and terms of use.

  • You will familiarise yourself with the patient information leaflet included with your order and any other information relayed to you via other means including IM/E-mail/telephone.

  • You will contact us and inform your GP if you experience any side effects to treatment, if there are any changes to your medical history including starting any new medications or new diagnoses, or if your symptoms/medical conditions change in any way.

  • You understand completing a purchase does not guarantee supply of treatment; the final decision to prescribe lies with the prescriber with your best interests, health and appropriateness in mind.

  • You agree to pay a non-refundable fee for our Trichology Prescriber to review your medical form for safe prescribing of your request. The charge for the review and consultation is £40, and upon approval of prescribing this amount will be deducted from your first prescription order.

Fee
bottom of page