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07425 899611

Hair Loss Consultation

Hair follicles on the head convert the hormone, testosterone, into a different form of testosterone called dihydrotestosterone (DHT). It’s believed that the gene for male pattern baldness causes the follicles to become sensitive to DHT and start to shrink. Eventually, the follicle stops working and no hairs will grow from it.

1. About your Health

To help us understand that this treatment is the right option for you, please answer the following questions.

0%

Please state your gender

This refers to your biological gender

Male

Female

What is your date of birth?

Use the calendar to select your date of birth.

Please add your height (in cms)

Your height is important for the prescribers decision.

Please add your current weight (in kgs)

Please make sure to add your current weight. This may affect the prescriber's decision.

Do you have any recent or past medical history of note?

If so, please provide more information

Yes

No

Do you suffer from any allergies?

If so, please provide more information

Yes

No

Do you currently take any medication whatsoever?

Please list all your current prescription medication including any medication you buy over the counter.

Yes

No

Is there a history of medical disorder's within your family?

If so, please provide more information

Yes

No

Are there any other health/medical details you feel we should know?

If so, please provide more information

Yes

No

2. About your Condition

To help us understand that this treatment is the right option for you, please answer the following questions.

0%

Is this a repeat prescription?

Yes

No

Are you suffering from hair loss?

Yes

No

Do you have hair loss in patches, or have an itchy or sore scalp?

Yes

No

Do you have a healthy scalp?

no inflammation on the scalp
no redness
no medical dressings
unshaven

Yes

No

Do you have sudden unexplained hair loss, or complete hair loss?

Yes

No

Could your hair loss be explained by any medication, dietary matter or illness?

Yes

No

Is your hair loss limited to the temple area?

Please Note: If so, we will still be able to offer you treatment, but with a limited medicine range.

Yes

No

Have you ever been diagnosed with one of the following conditions:

Heart Disease (including chest pain, angina, heart attack or any history of cardiovascular event)
High Blood Pressure
Pheochromocytoma (cancer of the adrenal glands)
Male breast cancer
Acute Porphyria (a rare hereditary disease affecting haemoglobin)
Prostate problems (prostate enlargement, prostatitis, prostate cancer)

Yes

No

Are you allergic/hypersensitive to minoxidil, finasteride/propecia, caffeine, ethanol, propylene glycol or lactose?

Yes

No

Do you have a history of depression or any other mental illness?

Please Note: If so, we will still be able to offer you treatment, but with a limited product range.

Yes

No

Are you taking any of the following medications?

Dithranol — used to treat psoriasis
Tretinoin — used to treat acne or other skin disorders
Corticosteroids — hydrocortisone or betamethasone dipropionate
Petrolatum — a common ingredient in hair wax and gel

Yes

No

Do you understand that if your partner is (or may be) pregnant, they should not handle crushed or broken tablets of finasteride, and that you should always wear a condom for sex?

Yes

No

Do you understand you should inform your GP that you are taking this medication if they are undertaking a PSA blood test for your prostate as the medication may affect the result?

Yes

No

Is there anything else which you feel we should know about prior to you taking this medication?

Yes

No

3. The Agreement and Consent

Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.

0%

Do you agree to the following?

You will read the patient information leaflet supplied with your medication
You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
The treatment is solely for your own use
You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.

Yes

No

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

Yes

No

About Us

Profarma Direct is a cutting-edge online pharmacy that specialises in lifestyle medicine and personalised prescriptions.

Marsh House Lane, Darwen, Lancashire, BB3 3JB, United Kingdom
07425 899611
For Sales & Orders:
info@profarmadirect.com
For General Enquiry:
info@profarmadirect.com

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How to check GPhC Registration

You can check our pharmacy details and registration status here. You can also see details of any Fitness to Practise decisions relating to a registrant.

GPhC Registration Number:

2076639

GPhC Registered Owner:

Profarma Direct Ltd

Superintendent Pharmacist:

Zakaria Jalgaonkar

GPhC Pharmacy Details:

Marsh House Lane, Darwen, Lancashire, BB3 3JB, United Kingdom

Copyright © 2024 Profarma Direct. All Rights Reserved.

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