Are you registered with a GP practice in the UK?
Do you give us consent to write to your GP for approval of this supply and to share information we hold about you?
(The information entered below in the medical assessment form will be treated with utmost
confidentiality whilst being reviewed by the prescriber. It will also provide the prescriber with
important information which will help them make an informed decision in deciding if the
treatment is considered to be suitable for you).
Do you believe you have the capacity to make decisions about your own healthcare?
Are you male and aged between 18 - 65?
Are you suffering from hair loss?
Do you have hair loss in patches, or have an itchy or sore scalp?
Is your hair loss limited to the temple area?
Are you experiencing any inflammation on your scalp?
Do you have sudden unexplained hair loss or complete hair loss?
Could your hair loss be explained by any medication or illness (e.g. chemotherapy or dietary)?
Are you allergic (hypersensitive) to Propecia (finasteride)?
Have you ever been diagnosed with prostate disease or male breast cancer or undergoing PSA (prostate monitoring) ?
Do you have a history of depression or any other mental illness?
Are you currently taking any medication (including over the counter, prescription or recreational drugs)?
Are you taking any of the following medications?
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?
Do you understand that Propecia may take up to 6 months before symptoms start to improve?
Some trials have suggested finasteride use may very slightly increase the risk of developing male breast cancer and prostate cancer. Do you agree to speak immediately to your doctor if:
Are you aware that Propecia may cause erectile dysfunction and you should speak to your GP if this happens?
Do you understand you must stop taking Propecia/Finasteride immediately if you experience any mood alteration including depressed mood, depression or suicidal ideation and should contact a healthcare professional?
Do you agree to the following?