If you are male, answer No

If you are male, answer No

If not, please explain why you need this treatment

If so, please provide more information

If so, please provide details of the medication and regime

If yes, please describe the reaction

- You declare that I have answered the above truthfully
- You will read the patient information leaflet before taking your medication (if prescribed)
- 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
- 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 understand that this questionnaire is part of a request to the doctor and the final decision will rest with the doctor

Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We advise you share this treatment with your doctor for him/her to update your medical records.