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.I agree to answer questions honestly and fullyYesNo Your ConditionMy hair loss is best described as;*My temples (front) onlyTemples and Crown of headStretching from temple to crownComplete loss of hair, top and sidesPatchy loss of hairHow long have you been experiencing hair loss?*Less than 6 monthsBetween 6 months to five yearsOver five yearsDo you have any itchy or dry patches of skin on your scalp?*NoYesHave you lost hair on other areas of your body? For example under your arms, on your chest, or genital areas?*NoYesWas your hair loss gradual or sudden?*GradualSuddenYour HealthDo you have any of the following medical conditions?* Rheumatoid arthritis Autoimmune disease Psoriasis Systemic Lupus Erythematosis (SLE or Lupus)Does anyone else, on either side of your family, suffer form male pattern baldness?*NoYesHave you previously been admitted to hospital due to a cystitis infection spreading to your kidneys?*NoYesPlease provide information*Are you currently taking any prescription-only medicines, alternative medicines or recreational drugs?*NoYesPlease provide information*Do you have any known allergies?*NoYesPlease provide information*What is your height and weight?*Imperial (cm and kg)Metric (Feet and Stone)Height (cm)Weight (kg)Height (Feet / Inches)Weight ( Stones / Pounds)ConsentI agree to the site's terms and conditions. I confirm I am over 18 years old. The medicine ordered is for my sole use only. I will read the patient information leaflet supplied with the medicine or obtain it from the website; I will especially take note of the side effects and dosages. I take responsibility to inform my own regular doctor of the online consultation or any changes in my circumstances.NoYes I Agree Choice of Medication*Finasteride 1mg x 28 (1 month) - £37.50Finasteride 1mg x 56 (2 months) - £69.50Finasteride 1mg x 84 (3 months) - £95.00Propecia 1mg x 28 (1 month) - £42.50Propecia 1mg x 56 (2 months) - £81.50Propecia 1mg x 84 (3 months) - £114.00Prescription 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.