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Hair loss, also known as alopecia or baldness, refers to a loss of hair  from part of the head or body. Typically at least the head is involved. The severity of hair loss can vary from a small area to the entire body.

ABOUT YOU

Are you male between the ages of 18-65?

YOUR SYMPTOMS

Are you currently 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 due to any medication or illness (e.g. chemotherapy or dietary)?

YOUR HEALTH

Are you allergic (hypersensitive) to Propecia (finasteride)?

Have you ever been diagnosed with a prostate disease or male breast cancer?

YOUR MEDICATION

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

AGREEMENT

Do you understand that if your partner is (or could 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/Finasteride 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:

  • You experience any changes in breast tissue such as pain, lumps or discharge from a nipple
  • You experience any pain, impotence, problems with ejaculation or loss of libido

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 develop depression and should contact a healthcare professional?

Do you agree with 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 a new medication or if your medical conditions change during treatment.
  • The treatment is solely for your own use
  • You give permission to access you NHS Summary Care Record in order to identify you correctly, check your medical history and provide the best possible care.
  • You give permission to contact your GP to inform them of your treatment.
  • 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.
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