Medical | MHR Clinic | Hair Restoration Specialists

First Name *

Last Name *

Sex at Birth *

Date of Birth *

Contact Number *

Email Address *

Street Address *

City

County

Postode *

Country

Clinic Location *

Doctors Surgery *

Please state if you have any allergies:

Are you taking or potentially about to start taking Propecia or Finasteride? *

What dose and for how long?

Requested length of Finasteride 1mg on this prescription *

Have you ever been diagnosed as having any of the following?

High blood pressure *

If yes *

Low blood pressure *

If yes *

Blood Pressure *

Epilepsy *

If yes *

Scalp Psoriasis/Eczema *

If yes *

Scalp Herpes *

If yes *

Scalp Dermatitis *

If yes *

Scalp Allergy *

If yes *

Scalp Infection *

If yes *

Phaeochromocytoma (kidney Tumour) *

If yes *

Have you ever had medication relating to your prostate? *

If yes *

Have you ever had your PSA levels checked? *

If yes *

Any other comments/medical history

Signature *

Date of Signature *

Confidential And Personal Medical Questionnaire