Hair Loss Archives - Online Chemist Shop | My Chemist Plus Pharmacy

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November 26, 2019 / bymedical / 0

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You have read the patient information leaflet provided in the further information link and confirm the medication is suitable for you and will follow the manufacturers instructions Yes No
Do you have any medical conditions Yes No
Do you take any medication or drugs (herbal or recreational). Yes No
Are you pregnant or breast feeding Yes No
Do you agree to the following? You have answered all the above questions accurately and truthfully. You understand our pharmacist's take your answers in good faith and base their decisions accordingly, and that incorrect information can be hazardous to your health. We need to ensure that this medicine is suitable for the person it is intended for. Therefore may be required to contact you by phone, If we are unable to speak to you when required your order may be delayed. You will seek medical advice if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment. Yes No
Why do you want to buy this online? I cannot get to my GP It is convenient I'm using more than my GP would allow I have lost my medication I need spare or extra medication
Would you like us to inform your GP about this order? Yes No
More Info
Terms & Conditions I confirm that I'm over 18 and I agree to the terms and condition

Submit Questionnaire
Start FREE consultation Yes
Are you a male or female? Male Female
What is your date of birth?
What is your height?
What is your weight?
What is your blood pressure?
Do you have any allergies? Yes No
Do you smoke, drink alcohol or take any recreational drugs? Yes No
Do you take herbal, homeopathic or ayurveda medicine? Yes No
What diagnosis/treatment do you require medicine for and what medicine has your doctor recommended in the past?
Have you seen your Doctor about the present condition? Yes No
Is your doctor aware of the medicine you intend to buy and are you going to inform your Doctor that we issued you this medicine? Yes No
Have you taken this medicine before with a prescription in less than 6 months ? Yes No
Do you suffer from any cardiovascular (heart) disease or have you ever had a stroke? Yes No
Do you suffer from transient ischaemic attack(s)? Yes No
Do you suffer from liver, kidney or gallbladder disease? Yes No
Do you suffer from stomach or bowel disorders (IBS), colitis or crohns? Yes No
Do you suffer from thyroid disease? Yes No
Do you suffer from asthma, bronchitis, emphysema or COPD? Yes No
Are you pregnant, breast feeding or planning to get pregnant? Yes No
Do you suffer from diabetes? Yes No
Do you suffer from high cholesterol or triglycerides? Yes No
Do you have prostate hypertrophy/enlargement or urine retention? Yes No
Do you have fever, diarrhoea or any other symptoms that might indicate that you may have an infection? Yes No
Are you currently suffering from any infections, e.g. ears, nose, throat, STI, urinary tract, skin? Yes No
Is there any historic disease or disorder that runs within your family? Yes No
Do you have any other disease, disorder or medical problem that the prescribing doctor needs to know? Yes No
Are you currently taking any other medication, other than this selected medicine, including prescribed and over the counter? Yes No
Do you currently have or ever had any problems like allergic reaction, side-effects or drug abuse by using this or other medicines? Yes No
Have you ever had any minor or major surgery? Yes No
Are you under the care of a psychiatrist? Yes No
Do you suffer from any suicidal thoughts or psychic problems? Yes No
Have you had any psychiatric referrals or consultations in the last 3 year? Yes No
Do you take any antidepressants? Yes No
Do you suffer from sleep apnoea? (failing to breath during sleep) Yes No
Do you suffer from hair loss? Yes No
Have you tried any medications to help your condition before? Yes No
Are you thinking of trying for a child in the next 12 months? Yes No
Are you being treated or being tested for benign prostatic hyperplasia or prostate cancer? Yes No
I understand that Finasteride/Propecia is dangerous for women and I will use a condom during intercourse.
I understand that Finasteride/Propecia can harm an unborn or newly born baby, and that pregnant women should not handle the medication.
Do you understand that Propecia may take up to 6 months before symptoms start to improve Yes No
Do you have hair loss in patches, or have an itchy or sore scalp? Yes No
Is your hair loss limited to the temple area? Yes No
Are you experiencing any inflammation on your scalp? Yes No
Do you have sudden unexplained hair loss or complete hair loss? Yes No
Could your hair loss be explained by any medication or illness (e.g. chemotherapy or dietary) Yes No
Have you ever been diagnosed with prostate disease or male breast cancer? Yes No
Please advise us upon the number of tablets left with you, whether it is prescribed by this online doctor service or from any other services including your own GP or Family/Hospital Doctor?
Have you seen your General Practitioner (GP) or Family/Hospital Doctor about the condition you require this medication for? Yes No
Have you taken this requested medication before, and was it initiated by your G.P or Family/Hospital Doctor? Yes No
I confirm that all the information provided is accurate. In addition I will only take this medicine according to the Doctors prescription dose and notify my own Doctor upon the purchase of this medicine.
I agree to read the relevant patient information leaflet before taking any medication if I am prescribed.
I give permission to allow the company to use my personal data strictly for processing my order which includes for use in credit/debit card processing, credit reference (CRA) and fraud prevention (FPA) agencies to help them make decisions on the legitimacy of my order.
Would you like to opt in to receive reminders for re-ordering of your repeat monthly medication? Yes No
Would you give us permission to contact your doctor if we need to discuss your treatment and to keep them informed about any medications prescribed for you? Yes No
Terms & Conditions I confirm that I'm over 18 and I agree to the terms and condition

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