Finasteride 84 Tablets

Male Hair Loss

Are you male?

Yes

What is your date of birth?

Have you had this medicine before?

Yes

If you answered yes, please provide further information regarding any previous side effects and how long you have taken it for?

Has your hair loss come about gradually or suddenly?

Gradually

Suddenly

Describe your pattern of hair loss:

From the crown of my head

From the crown of my head and my temples

From my temples only

In patches all over my head

Are you already taking Propecia (finasteride), Proscar or Avodart (dutasteride) for a condition other than hair loss?

Yes

Do you suffer with allergies?

Yes

If you answered yes, please provide details on your allergies

Do you have any kidney or liver problems?

Yes

If you answered yes, please provide details on your kidney or liver problem

Could there be any other explanation for your hair loss including stress, chemotherapy, or poor diet?

Yes

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

Yes

Are you currently taking any other medication including over the counter medication, herbal medicines or recreational drugs?

Yes

If you answered yes, please provide details on your medication or drug usage

Is there any other relevant information our prescriber needs to know in order to prescribe this medication safely to you?

I confirm the following:

I have read the patient information leaflet and understand the risks and benefits of taking this medicine.
I have answered all of the above questions accurately and confirm that the medication is for my personal use only.
I understand that finasteride should not be taken by women and in pregnancy, it may harm the unborn foetus. Also, women of childbearing age should not handle crushed or damaged finasteride tablets.
I agree to be treated by the prescribers and healthcare professionals at Linthorpe Pharmacy for my medical condition.
I will contact a medical professional if I have any questions or experience any unusual side effects from my treatment. I understand that I should inform my own GP that I am taking this treatment so they can see a full and accurate picture of my health.
We collect information about your health to make a medical diagnosis and prescribe medicines safely. Under the GDPR this type of data is classed as sensitive and therefore we take further precautions when collecting and processing it. By consenting to this notice, you are giving us permission to process your health data for the purposes of prescribing medicine.
Please be aware that Finasteride can affect the results of a PSA test for prostate cancer. If you ever require a PSA test you must inform the doctor you are taking Finasteride
I understand there have been rare cases of patients developing depression whilst on this medication. If I develop depression, I will stop taking this medicine immediately and inform a healthcare professional.

I have read and agree to the Terms and Conditions and Privacy Policy

Finasteride 84 Tablets

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