Please answer the following questions about yourself (the person who will take this medicine). If you get stuck or need any help, use our CHAT button below providing your contact details.

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Please select your option

Male
Female
Prefer not to say

Please select your option
Presently Pregnant
Presently Breastfeeding
Planning on getting pregnant
Neither Pregnant nor Breastfeeding

  • Cardiovascular (heart) or have had a stroke
  • Liver or Kidney problems
  • Diabetes
  • Thyroid
  • Immune System
If yes please provide more details

  • OTC (bought medicines)
  • Supplements
  • Herbal Medicines
  • Recreational Drugs



 

If yes please provide more details


If Yes please provide more details on how many units per week and usually when consumed

If yes please provide more details

Please provide more information on the type if you do

e.g. I live with 2 people and a cat, am a painter and decorator

If yes please provide more details

If yes please provide more details




Please answer the following questions to help us understand more about your symptoms and health

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  • Cyclosporine
  • Glucocorticoids (prescription steroids)
  • Minoxidil 
  • Phenobarbitone
  • Phenytoin
  • Hormone replacement therapy (HRT) with male hormone-like effects, such as Androfem or Testogel

  • Sudden or rapid hair growth
  • Hair growth extending to your back, chest or abdomen
  • Hair loss from the scalp, voice deepening, increased muscle bulk, or enlarged clitoris
  • Abdominal pain or swelling
  • Unexplained weight gain
  • Stretch marks or easy bruising
  • Unusual vaginal bleeding or changes in discharge






Please confirm your agreement to our prescribing partnership

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  • You will read the patient information leaflet supplied with your medication. The treatment is solely for your use (or the person you have completed this for and with their consent). 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.

We advise you share this treatment with your doctor so they can update your medical records.