Are you pregnant or breastfeeding or intending to become pregnant?Bottom of Form

Do you have any problems with your liver or kidneys?

Do you have any allergies?

• You have an allergy to Eflornithine
• You’ve used this treatment in the past and suffered with serious side effects
• You’re plan to use Vaniqa to remove hair on an area other than your face
• You are a male

I understand Vaniqa slows down hair growth, but Vaniqa is not a hair-remover

I understand Vaniqa is for long-term use and may take up to 4 months to work

I understand I should NOT stop prescription medicines when using Vaniqa

I understand Vaniqa is used only on the face and is untested and NOT likely to work on other parts of the body

Are you taking any other medications?

Do you understand you should NOT stop prescription medicines when using female facial hair treatments?

Do you understand you should NOT stop prescription medicines when using female facial hair treatments?

Do you know the cause of your facial hair?

Have you been diagnosed with Hirsutism (excess hair growth) by a medical professional?

Do you have any of these symptoms?

• Hirsutism that began after puberty
• Rapidly progessing facial hair
• Virilization (hair loss from the scalp, a deeper voice, increased muscle mass and an enlarged clitoris)
• Irregular periods (unless alrady diagnosed with these as a result of polycystic ovary syndrome)
• Abdominal pain or swelling
• Face becoming rounded
• Weight gain ni the neck and back that causes a hump
• Purple stretch marks
• Bruising easily
• Muscle weakness

Do you agree to the following?

• You will read the Patient Information Leaflet supplied with your medication
• 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
• The treatment is solely for your own use
• You are over the age of 18 and you have entered your own information for our identity verification checks
• You have answered all the above questions accurately and truthfully
• You understand our doctors take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
• You will inform your own GP of this purchase if appropriate
• You have read our privacy policy, cookie policy, patient agreement, data sharing agreement and Terms & Conditions

What is the name of your GP surgery and do you consent to us contacting them about your treatment?