Hair Loss Medication & Prescription

Symptons

Medical History

Medication

Male Patients Only

Female Patients Only

Medication History

Agreement

1. By agreeing to these terms, I acknowledge that my personal information will be disclosed to the prescriber responsible for approving my prescription. I understand that the prescriber may need to contact me to discuss my medical history or address any concerns related to my prescription.

2. I understand that I would need to take the treatment for at least 3-6 months before I see any benefit, and stopping treatment will reverse any regrowth and hair loss will resume.

3. I understand that as my prescription is customised specifically for me and is an unlicensed medication. Unless directed otherwise, the prescriber will send this prescription directly to the Compounding Lab Ltd T/A Compounding Chemist, who will compound the medication to the standards underpinned in Section 10 of the Medicines Act 1968.

4. Male patients - I also understand that this medicine can affect prostate blood test results. So if I need a prostate blood test, I will tell my doctor that I take finasteride or propecia.

5. Finasteride/Dutasteride/Spironolactone Prescriptions Risks- I understand that if I am trying for a baby or my partner is pregnant or I am pregnant, I should not use this medication as it adversely has an impact on the foetus.

6. Finasteride/Dutasteride/Spironolactone Prescriptions Risks - You MUST stop 6 months prior to planning a pregnancy.

7. Finasteride/Dutasteride Prescriptions Risks - Mood alteration such as depressed mood, depression, and less frequently, suicidal thoughts, has been reported. If you experience any of these symptoms, please stop the medication immediately and contact your GP or another healthcare professional.

8. Finasteride/Dutasteride Prescription Risks - Some trials suggest Dutasteride may slightly increase the risk of developing breast cancer and prostate cancer. If you experience changes in breast tissue (lumps, pain or nipple discharge), please speak to your GP.
9. I confirm that I have understood the questions asked, have answered them honestly, and that this treatment is for myself only. I understand the side-effects, other treatment options available, and that I can contact the prescriber for more information.

10. The risks and potential side effects associated with medications have been explained to me, and I have had the opportunity to ask any questions concerning this treatment.

11. Medications will be delivered to the address confirmed at the time of order.

12. Medications will be delivered through a courier tracked service.
13. Your confidential information will be processed and used for the above services under the current data protection requirements this may include:

• For record keeping purposes.

14. I understand that I must inform my GP of the medication:
    1. If I experience any side effects of treatment
    2. If I start any other new medication
    3. If my medical conditions change during the course of treatment
15. I understand that I must carefully read the patient information leaflet supplied with the medication.

If you would like to change or withdraw your authorisation for any of the above services, please contact a member of the pharmacy team who will update your preferences on info@cchemist.com or 0203 7732 729.