Highfield House – Hair Loss Solutions with Dr Moussa

First Name

Last Name

Phone

Email

Date of Birth

Occupation

Address.

⚠ Important Medical Information

Before proceeding, please confirm that you understand the following:

All medications have side effects.
Your prescription will be reviewed by a doctor before approval.
Some treatments are not suitable for certain medical conditions.

Declaration 1

I understand that all medications have potential side effects

Declaration 2

I understand my prescription will only be approved after doctor review.

Declaration 3

I confirm I have read all important medical disclaimers below

Possible Side Effects

Finasteride: Possible side effects include reduced libido, erectile problems, mood changes, and breast tenderness. NHS information
Minoxidil (oral or topical): Possible side effects include irritation at the application site; unwanted hair growth in other areas; headaches, dizziness or palpitations in some cases. NHS information

Do you have any medical Conditions

Yes

No

Please Give Details

Are you taking any medications?

Yes

No

Please give details

Have you been diagnosed with Hair Loss

Yes by a GP or specialist

No (Self Diagnosed)

Have you noticed any other changes to the areas where you are losing hair?

Yes

No

Please Give Details

Which of the following best describes your hair loss? (Tick all that apply)

Temples only (receding

Temples and Crown

Random patches – more details

General Thinning

Have you used any hair loss medications or treatments before?

Yes

No

Text Input

Was it Effective

Yes

No

Any Side Effects?

Yes

No

Please give details

Any Previous Hair Transplant

Yes

No

details of Your Procedure

Do you have any conditions affecting your liver, kidneys, prostate or urinary system?

Yes

No

Details Please

Are you taking any medication for high blood pressure (hypertension) or Prostate?

Yes

No

Give Details

Are you allergic to anything?

Yes

No

Details of any allergies

Are you or your partner pregnant or trying to get pregnant?

Yes

No

Important: Some hair loss medications are not safe during pregnancy. Please consult your doctor before proceeding.
👉 Read more on the NHS website: Fertility & Pregnancy While Taking Finasteride.

Depression

Some people when taking this medication have experienced mood swings. If you notice that your mood is affected and speak to your doctor.

Click to confirm

Erectile Dysfunction

One of the side effects of finasteride and dutasteride, which occurs in around 2% of men, is problems with sexual function, including erectile dysfunction, meaning your symptoms of ED may worsen.

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Click to confirm

Please provide us with pictures of your hair to aid us with your assessment.

This will help us to advise you correctly

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Medication Assessment

⚠ Important Medical Information

Possible Side Effects

Depression

Erectile Dysfunction

Please provide us with pictures of your hair to aid us with your assessment.