Raf

Medical Assesment Female Facial Hair

About You

Are you registered with a GP practice in the UK?

Yes No

Do you give us consent to write to your GP for approval of this supply and to share information we hold about you?
(The information entered below in the medical assessment form will be treated with utmost confidentiality whilst being reviewed by the prescriber. It will also provide the prescriber with important information which will help them make an informed decision in deciding if the treatment is considered to be suitable for you.)

Yes No

Do you believe you have the capacity to make decisions about your own healthcare?

Yes No

Symtoms

Have you noticed any of the following symptoms?

Hair loss from the scalp
Deepening of voice
Increased muscle bulk
Tumours (eg pelvic or abdominal mass)

Yes No

Have you previously seen your doctor about treatment options for your facial hair?

Yes No

Health

Do you suffer from any problems with your kidneys, your urinary system or with your liver?

Yes No

Are you pregnant or planning to become pregnant or breastfeeding?

Yes No

Medication

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

Yes No

Do you understand that Vaniqa works by slowing down growth of facial hair. It does not remove hair

Yes No

I understand usage of Vaniqa should be limited to the face and adjacent involved areas under the chin?

Yes No

I understand Vaniqa is applied daily and results may be seen as early as 4-8 weeks or up to 4 months?

Yes No

Agreement

I confirm I am over 18 years old.
The medicine ordered is for my sole use only.
I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.
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.
I consent to being contacted by telephone or email should the pharmacist require further information to assess my order.
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.
You are aware you will be subject to an ID check to verify your ID via LexisNexis Risk Solutions.

Yes No

I agree to the Terms and Conditions and I confirm that I am over 18.

The decision about the treatment offered is for both the prescriber and patient to jointly consider. However, the final decision will always lie with the prescriber which will ensure patient safety is not compromised. If treatment is refused, you will be signposted to another service and given a full refund.