1 IMPORTANT!2 Your Condition & Your Health3 Product Choice4 Details & PaymentWe will now ask you some questions to assess your suitability for a prescriptionJust before you start, it is important that you read this:Welcome to our online clinic. This questionnaire forms the basis of today's consultation. We need you to be honest with your answers so we can prescribe medication safely and give you the right advice. If you forget to tell us something or give inaccurate information, this may result in a drug being prescribed that harms rather than helps you. It's important that you tell us about any medication you are already taking when we ask for this.Facial Hair can sometimes be as a result of acne, irregular periods or scalp hair loss. These can be indicative of an underlying condition, and so you should speak to your GP rather than continue. If your facial hair growth has been sudden, you should also stop, and speak to your GP.*I don't have any of the above problems, and wish to proceed. Which part(s) of your body are affected by excess hair growth?* Face Neck Back Chest OtherVaniqua will not help with groith of hair on your backVaniqua will not help with groith of hair on your ChestWhich other areas are affected by excess hair growth?*Has there been an unusual and sudden growth of hair in the last few weeks/months?*NoYesWhat does the excess facial hair look like?*Soft / Fine / ClearThick / CoarseVaniqua will not help with groith of thin, fine hair. It is only useful where hair is thick and coarseHow would you describe your periods?*Regular, MonthlyIrregularI take hormones to stop themI am in my menopauseOther - please describeYour HealthAre you taking any prescription medicines?NoYesPlease provide details*Do you suffer any allergies?NoYesPlease provide details*Have you ever been diagnosed with a kidney or liver condition?*NoYesPlease provide details*Are you pregnant, planning to become pregnant or breastfeeding?*NoYesPlease provide details* Choice of MedicationVaniqua 80g x 1 (£74.00)Vaniqua 80g x 1 (£140.00)Vaniqua 80g x 1 (£206.00)Prescription Charge £ 5.00Total £ 0.00 Name* First Last Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Email* Phone* This iframe contains the logic required to handle AJAX powered Gravity Forms.