Medical assessment form

Before you begin taking any hair loss medication, we require you to answer the following questions regarding your medical history. Please answer all questions honestly and in full. All answers are treated in strictest confidence.

Which products are you interested in purchasing?(Required)

Are you currently taking any topical or oral medication (including over the counter, prescription or recreational drugs)?(Required)

Yes

No

Are you taking any non-steriodal anti-inflammatory drugs (NSAIDs)?(Required)

Yes

No

Please list all the medication you are currently using/taking.(Required)

Your name(Required)

First Last

Email(Required)

Enter Email Confirm Email

Telephone(Required)

Date of birth(Required)

Address

Street Address Address Line 2 City County / State / Region Post Code Country

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. 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.

5. 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.

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

7. Medications will be delivered through a courier tracked service.

8.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. 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.

By completing this form, I acknowledge and consent to the aforementioned statements.

By submitting this form, I acknowledge and consent to the aforementioned statements.(Required)

I have read the aforementioned statements.

I am happy for Hair Medics UK to share my data with Compounding Lab Ltd (trading as Compounding Chemist) to process my prescription.(Required)

Yes