Your Health
The information you provide us is treated with absolute confidentiality and will be reviewed by our experienced UK prescribers. We ask the following questions to provide the prescriber with an appropriate level of information to make an informed decision on whether the treatment is suitable or not.
What is your gender?
Please provide more detail.
Do you need help completing this questionnaire?
Please contact us on 020 7157 9759 or email [email protected] and we can assist you.
Do you believe that you have the capacity to make decisions about your own healthcare?
Sorry we can't offer you this treatment, please contact your GP.
Have you been diagnosed with any medical conditions?
Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.
Do you suffer from any allergies?
Please provide details including which allergies and what symptoms you experience.
Is there anything else you would like to include to allow our prescriber to prescribe responsibly?
Medical Questions
Have you seen your doctor before regarding your facial hair problem?
Please provide more details about the history of your facial hair
Vaniqa is for LONG TERM use and I understand that it could take up to 4 months to see the effects?
Some people have seen improvement in 8 weeks, however it is person specific. We want to make sure you understand all medication is the same but works differently for everyone.
I am aware that Vaniqa is not used for hair removal, it just slows down the hair growth?
Vaniqa slows hair growth down, however for best results you can use something to remove the hair as well
I Understand that:
Are you pregnant, breastfeeding or trying to have a baby?
Please provide more details
Consent
Would you like us to notify your GP of the treatment you chose to order today?
Please provide details.
It is very important that your GP is aware of all the medication you are taking, so that you are receiving the best possible care. You should only select “no” if you are completely sure you do not wish us to tell your GP.
Do you agree to the following:
If treatment is not suitable, you will be fully refunded and signposted to another point of care. The decision about the treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.
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