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OnlineDoc Treatment
Hair Loss Treatment
Only
€
23 per Script
Hair Loss Treatment
First Name
Last Name
Date Of Birth
Email
Phone Number
Address
Please specify your gender:
*
Male
Female
What level of male pattern baldness you are currently suffering from?
Choose an option
If Others, Please specify:
How long you are suffering from male pattern baldness?
*
FOR LESS THAN ONE MONTH
FOR 1-6 MONTHS
FOR MORE THAN 6 MONTHS
Did you start loosing hair suddenly or gradually?
*
Gradually
Suddenly
Do you have any rough, scaly patches or any itchiness on you scalp?
*
No
Yes
If Yes, Please specify:
Do you have any of the following medical conditions?
*
Required
NONE OF THE LISTED MEDICAL CONDITIONS
PSORIASIS
RHEUMATOID ARTHRITIS
SYSTEMIC LUPUS ERYTHEMATOSIS (SLE OR LUPUS)
AUTOIMMUNE DISEASE
OTHER CONNECTIVE TISSUE ILLNESSES
If other, please specify:
If Others, Please specify:
Do you have any family history of male pattern baldness?
*
No
Yes
If Yes, Please specify:
Do you smoke cigarettes?
Choose an option
Have you used before Finasteride, Fintid, Proscar or Profal before?
Choose an option
Do you have a significant past medical or surgical history?
*
No
Yes, (If yes, How many per day or per week. Please specify below)
If Yes, Please specify:
Are you allergic to any medication or any other substance?
*
No
Yes
If Yes, Please specify:
Please provide the name and address of the pharmacy where you'd like to pick up your medications.
I confirm that the answers I have provided for the above questions are true and accurate to the best of my knowledge.
*
I Confirm
I Do Not Confirm
I confirm and agree that any treatment prescribed for me is for my personal use only.
*
I Confirm
I Do Not Confirm
I fully understand the side-effects of the treatment options, their effectiveness and alternative options and am happy to continue with my request.
*
I Confirm
I Do Not Confirm
Proceed to Checkout
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