• Important
  • Hair loss subscriptions
  • Consent
Our doctors would now like to check your suitability for this product

How did you hear about us?

I confirm the above We are now going to ask you a few questions so that we can give you the best medical care. This takes an average of 5 minutes to complete.

We try our best to help our patients, but sometimes our online service is not able to meet all your needs.

Please be honest and if you are unsure about any of the answers, check these with your GP first.
--I am 18 years old or above
--I am using this service on my own behalf and of my own free will and any treatment or advice is for my sole use only
--I will see my GP if I need help filling out this form, reading or understanding this consultation
--I understand my consultation will not be passed to the Your Chemists Online Doctor clinical team until I have successfully completed payment
--I understand Minoxodil 5% solution is "off-label" in men aged over 65 and Regaine® 5% foam is off-label in men aged over 50


We want to offer you high quality, safe care. To do this we need you to be honest with your answers. Serious clinical errors could occur if you don't give us accurate information. Thank you for using our service.

What is your sex?

What is your date of birth?

Please select which of the images below best represents your hair loss

Do you have any itchy or rough patches on your scalp?


We want to offer you high quality, safe care. To do this we need you to be honest with your answers. Serious clinical errors could occur if you don't give us accurate information. Thank you for using our service.

I confirm the above Please confirm the following to complete your consultation:

--I have responded honestly and provided complete and accurate information that reflects my up to date medical history and information, so that the Your Chemist Online Doctor clinician can safely assess and advise me.
--I fully understand all the questions and information provided. If I am unsure about any aspect of the service I will contact Your Chemist Online Doctor before proceeding.
--I understand the side effects, effectiveness and alternatives to the treatment I am requesting.
--I understand the importance of notifying my GP about medicines and advice I may receive from this service so they can continue to provide safe medical care.
--I understand this consultation will form part of my Online Doctor medical record and will be kept in line with the relevant retention period.
--I have read, understand and agree to the terms and conditions and privacy policy notice.


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