How did you hear about us?
I confirm the above We are now going to ask you a few questions so that we can give you the best medical care. This takes an average of 5 minutes to complete.We try our best to help our patients, but sometimes our online service is not able to meet all your needs.Please be honest and if you are unsure about any of the answers, check these with your GP first.--I am 18 years old or above--I am using this service on my own behalf and of my own free will and any treatment or advice is for my sole use only--I will see my GP if I need help filling out this form, reading or understanding this consultation--I understand my consultation will not be passed to the Youth and Earth Labs Online Doctor clinical team until I have successfully completed payment--I understand Minoxodil 5% solution is "off-label" in men aged over 65 and Regaine® 5% foam is off-label in men aged over 50
We want to offer you high quality, safe care. To do this we need you to be honest with your answers. Serious clinical errors could occur if you don't give us accurate information. Thank you for using our service.
What is your sex?
What is your date of birth?
Please select which of the images below best represents your hair loss
Do you have any itchy or rough patches on your scalp?
Please tell us Have you lost any hair in other areas of your body such as eyebrows or beard? And have you taken Propecia or Finasteride for hair loss before? Did the medication work for you and any of the side effects with Finasteride or Propecia? Are you taking Propecia, Finasteride or Dutasteride for prostate problems and have you ever had any of the conditions such as Alopecia, Breast cancer, Depression, Obstructive uropathy, Prostate cancer, Kidney condition or Liver condition? If you have any of the conditiond then please provide details regarding the condition.
I confirm the above Please confirm the following to complete your consultation:--I have responded honestly and provided complete and accurate information that reflects my up to date medical history and information, so that the Youth and Earth Labs Online Doctor clinician can safely assess and advise me.--I fully understand all the questions and information provided. If I am unsure about any aspect of the service I will contact Youth and Earth Labs Online Doctor before proceeding.--I understand the side effects, effectiveness and alternatives to the treatment I am requesting.--I understand the importance of notifying my GP about medicines and advice I may receive from this service so they can continue to provide safe medical care.--I understand this consultation will form part of my Online Doctor medical record and will be kept in line with the relevant retention period.--I have read, understand and agree to the terms and conditions and privacy policy notice.
