Simple Online Pharmacy

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1Your Hair Loss

Please select the pattern of your hair loss according to the chart below.

Do you understand that all our hair loss treatments are for men between 18-65 only?

NOTE: These medicines will not work in women and can be harmful during pregnancy *

NoYes

Please provide more information below. *

What was your sex registered at birth? (i.e. your biological sex) *

Was your hair loss either sudden or medication induced? *

NoYes

Please provide more information below. *

Does your hair fall out in patches? *

NoYes

Please provide more information below. *

Are you suffering from an illness or skin condition that might explain your hair loss? e.g. Disease causing weight-loss or fevers or skin conditions such as psoriasis or ring worm *

NoYes

Please provide more information below. *

Are you currently taking, or have you ever taken, Finasteride (Propecia) or Dutasteride (Avodart)? *

NoYes

Have you noticed you have developed, or did develop, any of the following since you started taking Finasteride (Propecia) or Dutasteride (Avodart)? *

Do you believe Finasteride (Propecia)/Dutasteride (Avodart) was the cause of this issue? *

NoYes

Do you believe Finasteride (Propecia)/Dutasteride (Avodart) was the cause of this issue? *

NoYes

Do you believe Finasteride (Propecia)/Dutasteride (Avodart) was the cause of this issue? *

NoYes

2Your Health

Are you currently undergoing any investigations in relation to your prostate or have raised PSA (Prostate Specific Antigen) levels? *

NoYes

Do you suffer from, or have a history of, depression or suicidal ideation? *

NoYes

Are you taking antidepressant medication(s)? *

NoYes

Which antidepressant medication(s) are you taking, how long have you been taking them and are they stable? Please provide details for our GPs to review. *

Over the last 2 weeks, how often have you been bothered with feeling little interest or pleasure in doing things? *

Over the last 2 weeks, how often have you been bothered with feeling down, depressed or hopeless? *

Have you previously been diagnosed with or currently have any of the following:

Prostate cancer
Phaeochromocytoma
Severe liver impairment
Male breast tissue enlargement (Gynecomastia)
Kidney impairment
Breast cancer
Urine issues (such as difficulty urinating or obstructive uropathy)
Inflammatory bowel disease (such as colitis)

NoYes

Have you previously been diagnosed with or currently have any of the following:

Heart failure
Hypertension (high blood pressure)
Recent heart attack
Angina
Tachycardia (or any condition affecting your heart rate)

NoYes

Do you have any other health problems or conditions that you think we should know about? e.g. recent or major operations, G6PD, mental illness, neurological conditions etc. *

NoYes

Please give more details *

Are you currently taking any prescription-only medicines, alternative medicines or recreational drugs not already declared? *

NoYes

Are you using any medicines, creams or dressings for your scalp? *

NoYes

Please provide more information below *

Please give more details *

Do you have any known allergies to any medicine or substances? *

NoYes

Please give more details *

Is there any other information you feel would be useful for our clinicians to know about? *

NoYes

Please provide any additional information below *

We strongly advise that you inform your GP of any treatment you receive.
Would you like us to inform them on your behalf?

NoYes

Please enter your postcode to display your local GP's

Please enter your GP’s name and surgery address. Please also enter their email address and fax number, if you know it.

You can find your GP surgery information details below

Please enter your GP surgery name *

Please enter your GP surgery address and post code *

Please enter your GP surgery email

3Consent

You should promptly report to your doctor any changes in your breast tissue such as lumps, pain, enlargement or nipple discharge as these may be signs of a serious condition, such as breast cancer.

If choosing non-branded products, you may receive any make of Finasteride / Dutasteride. If you do have a specific brand preference please advise us by contacting our customer service team. We will try to accomodate these requests if possible.

Our doctors prescribe Dutasteride (Avodart) and Minoxidil (Loniten) 'off-label' for hair loss. We would recommend that the licensed product Finasteride (Propecia) is tried first before an off-label medication is used. 'Off-label' means the medicine is being used in a way that is different to how it's described in the medical license of the product. You can read more information here. This information will also be provided in your delivery.

Please tick to confirm you have read the above before proceeding.

Confirm

If selecting minoxidil tablets and you notice any shortness of breath, discomfort when breathing lying down, chest pain, chest fullness, lightheadedness/feeling faint and/or swelling of your abdomen or legs, please stop using minoxidil tablets and see your doctor right away - please tick that you understand *

Confirm

Some users of Finasteride (Propecia) and Dutasteride (Avodart) may experience depression or suicidal thoughts. Other people may experience decreased libido or sexual dysfunction.

NOTE: Please tick to confirm that you will discontinue using these medicines, and speak to your GP, should you experience any of these effects. If you have previously suffered from severe depression or suicidal thoughts or attempts, you should not use these medications and instead contact your GP for advice. *

Confirm

I am aware that this medicine can pass into semen. I’m aware that I should use a condom when having sex if my partner is pregnant or could get pregnant. I understand that I should discontinue Finasteride (Propecia) treatment for 2 weeks, or Dutasteride (Avodart) for 3 months, before trying to conceive. *

Confirm

I'm aware that I should tell my GP I'm taking Finasteride (Propecia) or Dutasteride (Avodart) if I have a blood test for prostate cancer called PSA (prostate-specific antigen). This is because these medicines can affect the result of this test. *

Confirm

I understand that I should not use Finasteride (Propecia) and Dutasteride (Avodart) together. *

Confirm

I confirm I am over 18 years old and will be using this medicine for hair loss

I confirm this treatment is for me, and I consent to this treatment.

I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.

I take responsibility to inform my own regular doctor of the online consultation or any changes in my circumstances.

I agree to the Simple Online Pharmacy terms and conditions. *

Confirm

If treatment is not suitable, you will be refunded and signposted to another point of care. The decision about the treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.

Assessment Progress

NHS Prescriptions made Simple

Assessment

1Your Hair Loss

2Your Health

3Consent