Scalp Problem ?
Brother or sister
Have spots or acne?
Prone to dandruff
Hypertension (High Blood Pressure)
Hypotension (Low Blood Pressure)
Polycistic Ovarian Syndrome
Barrier Contraceptives (ie condoms)
Lacto Vegetarian (milk/cheese and vegetarian diet)
Pescatarian Diet (Fish and Vegetarian Diet)
Vegan (Purely Vegetarian)
No Dramatic Weight Change
Please confirm the following to complete the consultation:
I agree that all information that I have given is true to the best of my knowledge and that I have not withheld information that could potentially be deemed relevant to a doctor's decision to prescribe medicines for hair loss. I agree that only I, the named patient completing this questionnaire, will take any medicines that I may be prescribed following submission of this form. I agree, prior to taking any medicines that may be prescribed, to read the patient information leaflet supplied with the medicines, and adhere to the instructions that accompany the medicines that I am requesting. I understand that there is a small chance of side effects that can occur from the hair loss medications offered by the rejuvenate pharmacy. The most common or relevant side effects related to the medicine or medicines that are prescribed to me should be explained by the adviser that contacts me, but should I have any further queries I will ask. I agree to notify The rejuvenate Centre if any side effects occur.
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