To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.

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If yes, please tell us what you are taking.




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  • Any unexplained spots or lesions
  • Any flaking
  • Any swelling
  • Any pain or inflammation
  • Active infection on the scalp
  • Psoriasis of the scalp

  • Uncontrolled high blood pressure
  • Breast cancer, prostate cancer pheochromocytoma
  • Enlarged prostate, BPH or PSA monitoring
  • Depression , anxiety or panic disorders
  • Cardiovascular disease (including chest pain, heart attacks, angina, or ischaemic heart disease)
  • Chronic kidney disease
  • Getting easily out of breath with light exercise (such as walking up stairs)

This can include:

  • Immune system conditions such as HIV
  • Liver or kidney issues

If yes, please list your medical conditions.


If yes, please list your allergies. 


If yes, please list what other medications you take.





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  • You are between 18-65 years old
  • To Inform both us and your GP about any treatment-related side effects, the initiation of new medication, or changes in your medical conditions during the course of treatment.
  • To read the patient information leaflet provided with your medication before using your new treatment. If you have any questions you can contact our support team or your GP.
  • The prescribed treatment is intended exclusively for your personal use.
  • You have provided accurate and truthful responses to all the preceding questions.
  • You acknowledge that our prescribers rely on your responses as truthful and honest to make prescribing decisions and recognise that inaccurate information may result in serious health risks.
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