Medical Questionnaire

General Information

Patient first name *

Patient surname *

Date of birth *

Email Address *

Mobile / Phone number *

Gender at Birth *

MaleFemale

Address *

Street address *Street address line 2

City *

Postcode *

Occupation

Do you smoke?

YesNoI used to smoke

Do you use recreational drugs?

NoI have previously usedI currently use

Health Information

Do you have any medical conditions, you are treated or known for ? i.e, asthma, eczema, hypertension , other *

YesNo

Please list all your medical conditions

Check the one which applies to you *

Pregnant Breastfeeding Planning to become pregnant in near future Not pregnant or breastfeeding

Any means of contraception? Please list i.e pill, coil, implant

Please list any condition which are significant and not mentioned

Are you taking any prescribed medications? *

YesNo

Please list your current prescribed medications, including dose

Are you taking any supplements, herbal treatment, alternative treatment? *

YesNo

Please any supplements, herbal treatment, alternative treatment you are currently taking

Do you have any medication allergies? *

YesNo

Please list any medication allergies

Do you have any other allergies and known intolerances ? i.e . pollen, plaster, food *

YesNo

Please list all your other allergies and known intolerances

Your Concern

WHAT IS YOUR CONCERN TODAY ? *

Hair and Beard Area ( hair loss, reduced density etc.)Skin Condition ( acne, rosacea, melasma, pigmentation etc)

Please provide more information

Provide more information

Please describe

Please provide more info

When did you first noticed your symptoms?

Has anyone in your family had the same symptoms or currently having?

History of treatment up to today. Please list all prescribed and over the counter treatment

Please upload clear and sharp photos of concerned areas. 2 minimum *

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Consent

By submitting this form, you are declaring that all the information provided is true and complete to the best of your knowledge. You confirm that you have not omitted any details that could affect your ability to receive treatment or safely use the product. You understand that providing inaccurate or incomplete information may impact the safety and effectiveness of your treatment. *

Signature

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