Skip to content

Online Pharmacy
Online Pharmacy

Allergy and Hay Fever

Analgesics

Home Blood Test Kits

Brain & Nervous System

Coughs-Colds-Flu

Eyes and Ears

Gastrointestinal

Heart Condition

Infants

Nutrition

Oral Health

Scalp Conditions

Skin Health

Women's Health
Aesthetics
Anti Wrinkle Injection

Aqualyx Fat Dissolving Injection

Dermal Fillers

IV Vitamin Therapy Essex

Lipo Cavitation Treatment

Platelet Rich Plasma Treatment

Trichology Clinic

Vitamin B12 Injection
Online Doctor
Mens Health

Erectile Dysfunction

Premature Ejaculation

Hair Loss

Urine Flow

Womens Health

Female Facial Hair

Progestogen-Only Pill
(Mini Pill)

Morning After Pill

Period Delay

General Health

Acid Reflux / Heartburn

Acne Treatment

Antimalarials

Asthma Inhalers / Salbutamol Inhalers

Chlamydia Antibiotics

Cold Sores

Cystitis Antibiotics

Eczema

Flu Antivirals

Genital Herpes

Genital Thrush

Hay Fever

Irritable Bowel Syndrome

Jet Lag

Migraine Relief

Rosacea Treatment

Stop Smoking

Travel Sickness

Travellers' Diarrhoea
Weight Loss
Wegovy

Mounjaro

Saxenda (Liraglutide)

Xenical

Orlistat

Rybelsus
NMN
Walk In
Ear Wax Removal

Hair Loss Centre

Hayfever Injection

Other Services

Private Blood Test

Pharmaceutical Compounding

Retail Pharmacy Outlet

Vitamin B12 Injection

Stop-Smoking Clinic

Travel Clinic

Yellow Fever Vaccination

£0.00 0 Basket

£0.00 0 Basket

Hair Loss Assessment

Hair Loss Treatment Medical Questionnaire

"*" indicates required fields

Step 1 of 8

12%

Ordered Before?

Please sign in and re-order. To ensure no delays to your order, we must have a medical questionnaire filled. Log In
You can order again by selecting the product from your dashboard, clicking Order Again.

Medical Questionnaire

Patient Notice: This Questionnaire forms the basis of your Hair Loss Treatment consultation today. We need you to be honest with your answers including any current medications you are on. This allows our doctors to prescribe medication that helps you and offer accurate advice. We expect you to read the medical information before selecting your treatment.

Your Symptoms

Have you noticed a significant increase in hair shedding when brushing or washing your hair?*

Yes

No

Please provide more information below.*

Do you observe thinning hair or bald patches on your scalp?*

Yes

No

Please provide more information below.*

Has the texture of your hair changed, becoming finer or more brittle?*

Yes

No

Please provide more information below.*

Is the hair loss localized to specific areas or more general across the scalp?*

Yes

No

Please provide more information below.*

Have you experienced any itching, burning, or irritation on your scalp associated with hair loss?*

Yes

No

Please provide more information below.*

Health

Are you currently undergoing any form of medical treatment or taking medication that could potentially contribute to hair loss, such as chemotherapy or thyroid medications?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Do you have any underlying health conditions, such as thyroid disease, anaemia, or autoimmune diseases, that might be linked to hair loss?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Have you had any recent significant stressors or life changes that could have triggered the onset or worsening of hair loss?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Are you following a balanced diet, or have you been diagnosed with nutritional deficiencies that could affect hair health, like low levels of iron or vitamin D?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Have you previously sought treatment for hair loss, and if so, what treatments were tried?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Acknowledgements

Please Confirm

I understand if I start to experience any symptoms that seem out of the ordinary, I must see a GP.

These questions aim to provide a comprehensive understanding of the patient's condition and any contributing factors, which is crucial for the safe and effective prescription of hair loss treatments.

Consent

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

Yes

No

Your GP Address Details

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Your Details

Name*

First Last

Phone*

Date of Birth*

Day

Month

Year

Your Home Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Please Confirm

Confirmation*

I Confirm

• I confirm I am over 18 years old
• The medicine is ordered for myself
• I will read the patient information leaflet supplied with the medicine and specifically the side effects and dosages
• I take responsibility to inform my own regular doctor of this online consultation or any changes in my circumstances.
• I agree to the Pharma Aesthetics Terms and Conditions.

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

Comments

This field is for validation purposes and should be left unchanged.

Ordered Before?

Sign In And Reorder Prescription

The One Stop Practice That Meets Your Health & Beauty Needs

Subscribe to our newsletter

Email

Order Today

Online Pharmacy
Online Doctor
NMN Supplements
Weight Loss
Cart
Checkout
My Account

Book Today

Online GP
Aesthetics Treatments
Walk In Service
Erectile Therapy

About

Returns Policy
Delivery
Feedback and Complaints
About us
Privacy Policy
Terms and Conditions
Contact us

Pharma Aesthetics Ltd © 2025 All rights reserved
Sitemap
Powered by Elliot Web Designs

Facebook Instagram

Search

Search

Order Today

Online Pharmacy
Online Doctor
NMN Supplements
Weight Loss

Book Today

Online GP
Aesthetics Treatments
Walk In Service
Erectile Therapy

Fb.
In.

Email Us >
01708 608860