Facial Hair

About You

1. Hi. What is your name?

2. Are you purchasing this medication for yourself?

Only the patient should be filling in the consultation.

Do not order medication for another patient or order multiple medications for different patients on a SINGLE order. Please register separate accounts for each patient as each account is treated as a medical record.

Yes No

3. Are you over 18 years old?

We cannot provide facial hair treatment to those under the age of 18. Please contact your GP for support.

Yes No

4. Are you breastfeeding, pregnant or planning to become pregnant?

Vaniqa is not advised during pregnancy. Appropriate contraception is recommended during treatment.

Yes No

4b. Please tell us whether you are breastfeeding or pregnant (and how many weeks)?

5. Have you previously discussed your facial hair with your GP/any other healthcare professional?

Yes No

5b. What was the cause of the hair growth?

6. Please tell us where the thick/dark hair is:

Chin

Jawline

Upper lip

Neck

Other

7. Have you noticed any of the following symptoms?

Sudden or rapidly worsening facial hair growth
Hair growth spreading to your chest, abdomen or back
Abdominal pain or swelling
Unexplained weight gain
Hair loss from the scalp, increased muscle bulk, voice deepening, or enlarged clitoris
Unusual vaginal bleeding, changes in your period (irregular or absent periods of premenopausal) or changes in discharge

Yes No

7b. Please tell us more:

8. Are you currently taking, or recently stopped taking any medicines (including over-the-counter medicines, herbal medicines or recreational drugs) - including any of the ones listed below?

Cyclosporin/ ciclosporin
Glucocorticoids (steroids for conditions such as rheumatoid arthritis or allergic conditions)
Minoxidil
Phenobarbitone
Phenytoin
Hormone replacement therapy with male hormone-like effects (such as Testogel)

Yes No

8b. Please provide more detail:

9. Do you have any other medical condition(s) or past surgical procedures?

Yes No

9b. Please provide more details:

10. Have you ever had any kidney impairment?

Yes No

10b. Please provide more details:

11. Do you have any allergies to medicines or substances (e.g. peanuts, soya etc.)?

Yes No

11b. Please provide more details:

12. Do you have, or ever had a diagnosis of PCOS, adrenal or ovarian tumors?

Yes No

12b. Please provide more details:

13. Would you like us to pass on details of your treatment to your GP?

Yes No

13b. Please provide your GP's details:

Please Provide GP Email (preferred):

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14. Please confirm you have read and understood the following statements:

I understand that:

Vaniqa is for long-term treatment and may take up to 2-4 months to show noticeable effects.
Vaniqa slows down hair growth, but is not a hair-remover.
Vaniqa is used only on the face/chin and should not be used on other parts of the body.
A patch test on my chin or neck is recommended before I start using Vaniqa on my face.
I should discontinue treatment if no beneficial effects are noticed within 4 months of treatment.

Yes No

15. Do you agree with the following?

I have read the information available on the treatments and medication web page and understand the side effects, effectiveness and alternatives available.
I have answered the questions honestly and accurately and the treatment is solely for my personal use.
I will read and understand the patient information leaflet supplied with my medication.
I understand that although it is not compulsory it is important to inform my GP of this treatment so they can provide safe healthcare.
I understand prescribing decisions will be based on the answers from my consultation and incorrect information can cause harm to my health. Orders may be rejected if not clinically suitable.
I am aware The Family Chemist will undertake a soft check to validate my identity using LexisNexis. Note: This does not affect your credit rating.
I have read and agree to our Terms and Conditions, Terms of Use and Privacy Policy.

Yes

16. I confirm that I have read the information in this questionnaire and will follow the advice from the patient information leaflet before using the provided treatments.

Yes

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Facial Hair

About You

Your Medical History

0115 850 1944

enquiries@thefamilychemist.co.uk

Unit 1, Wilford Business Park,
Ruddington Lane,
Nottingham,
NG11 7EP

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About You

Your Medical History

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