Name* First Last Date of Birth* DD slash MM slash YYYY Mobile Phone*Address* Street Address Address Line 2 City County Postcode Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Which of these pictures reflects your hairloss best?*--NAIIIIIIIIIvertexIVVVIVIIWhen did you first notice you were losing your hair?*--Less than 1 month ago1-6 months agoMore than 6 months agoHow did your hairless begin?*--Gradually over many months or yearsSuddenlyHave you ever taken Propecia or Finasteride?* Yes No NAAre you currently taking any medication, or have you recently finished a course of medication?* Yes NoDetails of Medication*Do you suffer from any problems with your kidneys, your urinary system or with your liver?* Yes No NAHave you ever been diagnosed with cancer of the prostate?* Yes No NADo you have hair loss in patches, or have an itchy or sore scalp?* Yes NoDo you have sudden unexplained hair loss, or complete hair loss, or hair loss caused by medication?* Yes NoAre you aware that Propecia tablets / finasteride 1mg / finasteride 5mg are for men or post-menopausal womenonly?* Yes No NADo you have any other health problems or conditions that you think we should know about? (e.g. mental illness, depression, anxiety, neurological conditions, recent or major operations, G6PD, etc.)* Yes NoHealth Problem Details*Communication between doctors involved in your treatment helps provide the safest and most effective healthcare. Would you like us to inform your GP about this treatment?* Yes NoI consent for this information to be shared with my prescribing surgeon and his clinical providers* Yes NoGP Details*Terms & Conditions* Please confirm that the following apply:I am over 18The tablets are for my own personal useI will read the Patient information leaflet supplied with the tablets and follow the prescriber's instructionsI confirm that I have read, understood and accept all information in the documents attached to the email sent to me and described at https://www.medicines.org.uk/emc/medicine/3679 regarding the side effects that may be experienced whilst taking Finasteride/Propecia.