Medical Assessment - Regaine Solution (Minoxidil 5%)

About You
Are you male aged 18-65?
Your Symptoms
Are you suffering from hair loss?
Do you have hair loss in patches, or have an itchy or sore scalp?
Is your hair loss limited to the temple area?
Do you have a healthy scalp?
  • no inflammation on the scalp
  • no redness
  • no medical dressings
  • your scalp is not shaved
Do you have sudden unexplained hair loss or complete hair loss?
Could your hair loss be explained by any medication or illness (e.g. chemotherapy or dietary)?
Your Health
Have you ever been diagnosed with one of the following conditions:
  • Heart Disease (e.g. angina or a heart attack)
  • High Blood Pressure
  • Pheochromocytoma (cancer of the adrenal glands)
  • Acute Porphyria (a rare hereditary disease affecting haemoglobin)
Are you allergic (hypersensitive) to Regaine (minoxidil), ethanol or propylene glycol?
Are you currently taking any medication (including over the counter, prescription or recreational drugs)?
Agreement
Do you agree to the following?
  • You will read the patient information leaflet supplied with your medication
  • You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
  • The treatment is solely for your own use
  • You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.


Complete our 2 minute questionnaire
We’re almost done!
Dr Oliver Large
To make sure this treatment is safe for you to take, we just need you to answer a few questions.
Dr Oliver Large
Confidential & Secure
  • Our prescribers will review your details in complete confidence
  • Your medication will be delivered in plain unlabelled packaging
  • Appears on your statement as “Mexpress”
  • All data is securely encrypted with 128bit SSL
Need help? If you need help with this medical assessment, contact our helpline:
0208 123 0508
or email us: help@medexpress.co.uk