Prescription Form

Full Name *

Email Address *

Phone *

Street Address *

Apartment, suite, etc

City

County

Postal Code *

Country

What is your gender? *MaleFemale

What is your date of birth? *

How is your general health? *

Have you ever had medication relating to your prostate? / had your PSA levels checked? *YesNo

Are you taking any other medication? *YesNo

If yes please provide additional information.

Do you suffer from high or low blood pressure *YesNo

If yes please explain

Do you suffer from any allergies? *YesNo

Please describe your allergies

Would you like us to inform your doctor of any treatments that are prescribed to you by MHR Clinic? *YesNo

Please provide your doctors Name and Address

Do you agree to read the patient leaflet before taking any medication prescribed to you?YesNo

How long have you suffered from hair loss? *

Was the onset of hair loss sudden or gradual? *

Any lifestyle circumstances that may have led to hair loss (eg. Physical or Emotional Stress, Weight Loss, Stress)?

Have you tried other hair loss remedies? *YesNo

Please describe other remedies explored.

Were any results seen?YesNo

Please explain the results you noticed

Did you notice any side effects from your treatment?YesNo

Please describe the side effects experienced

Are you currently being treated or tested for any cancer treatments? *YesNo

Please give more information

How long ago were you last treated or tested

I undertand

Credit / Debit Card *

GDPR *Yes, I agree with the privacy policy and terms and conditions.