HairLossXyon – Dickson Chemist

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– Step 1 of 21

The only hair health company founded by doctors — renowned specialists in hair restoration — with a focus on performance and side effect reduction

In order to start the consultation you must confirm that you are over 18 and biologically male

I agree

In order to complete this consultation, you must have recent photographs of your hair loss, and a photograph of your photographic government issued ID. If using a mobile device you can take photos as the consultation progresses. *

I understand

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Question 1 of 20: Do you have a partner or anyone in your household who you know is?

Pregnant
Trying to get pregnant
Breastfeeding
None of the above

You cannot proceed with the consultation if anyone in your household is pregnant, trying to get pregnant or breastfeeding.

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Question 2 of 20: When did you first notice hair loss or hair thinning?

Not started yet, I’m trying to prevent it
Recently within the last month or two
Over the last 6 months to a year
Over a year ago

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Question 3 of 20: In what areas are you experiencing hair loss or thinning? (Select all that apply)

Hairline (front)
Crown (top of scalp)
Across entire scalp
Along my parting
Eyebrows/eyelashes
Other

If you selected other, please tell us where

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Question 4 of 20: Have you ever had your hair loss evaluated by a physician?

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Question 5 of 20: Are you currently taking, or have you ever taken finasteride (e.g., Propecia™, Proscar™), dutasteride (e.g., Avodart™), minoxidil (e.g., Rogaine™), or any other medication for hair loss?

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Question 6 of 20: Do you have any of the following symptoms in addition to your hair loss?

Itching, burning, pain, bumps, sores or rashes on scalp sudden high volume of hair loss (hair coming out in clumps /shedding more than 100 hairs a day)
Sudden high volume of hair loss (hair coming out in clumps /shedding more than 100 hairs a day)
Smooth round patches of hair loss
Hair loss started after a major event (e.g. new diagnosis, medication, life stressor/trauma, surgery or cancer therapy)
I often wear my hair in ways that can stress my hair/scalp (tight braids, weaves, locks, ponytail)
None of the above

Our products do not treat infections, stress induced hair loss or physical abnormalities. We recommend seeing a physician with those symptoms in order to be assessed in person.

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Question 7 of 20: Please tell us a bit about your medical history. What conditions you have had diagnosed (if any) and what medication or therapy you are taking for them. If you are on no medication and have no conditions leave this box blank.

Medical history

In order to proceed, we must specifically confirm with you that you do not have a current or historical diagnosis of prostate or breast cancer *

I do not have either of these conditions

Legal Disclaimer: I understand that in order to be treated safely and effectively, I must be fully truthful and honest in this disclosure. It is my personal responsibility to disclose all medical information at this stage. (copy) *

I have disclosed all relevant medical information

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Question 8 of 20: To the best of your knowledge, do you have a family history of prostate or breast cancer in a first degree relative (e.g. Parent, sibling, child)?

Our products cannot be remotely prescribed to patients with first degree relatives who have these conditions.

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Question 9 of 20: Do you have a history of sexual dysfunction ? (e.g. erectile dysfunction, lower sexual drive/libido)

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Question 10 of 20: At your most recent physician visit or blood pressure reading, please select which of the following ranges your blood pressure was in:

Normal Range
Low
High
I don’t know or can’t remember

As the medications used can cause low blood pressure, we can only prescribe them remotely if you have a BP within a normal range.

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Question 11 of 20: If you are taking any vitamins or supplements, or herbal medicines not previously mentioned, please list them here.

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Question 12 of 20: Do you have any allergies or intolerances to food, dyes, medications, antibiotics, or anything else? If so, what are you allergic to? If you do not, please type N/A.

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Question 13 of 20: During your consultation with your prescribing consultant, there will be an opportunity to answer any specific questions you have. If you have anything you want to ask us, please let us know so we can be prepared.

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Question 14 of 20: Identification. Please enter all the details below – note, the name must match the photographic ID which we will ask you to upload. If you do not have photographic ID, a picture of you holding a utility bill is sufficient.

Name *

First

Last

treated front consultation

Email *

Confirm Email

Date of birth *

Date of birth

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Primary Care Physician Name and Surgery

By giving this information you authorise us to contact your NHS or regular doctor to let them know that we have prescribed you medication. This is good practice but you can opt out by not filling in this information, it will then be your responsibility to let your doctor know you are taking medication not prescribed by them .

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Question 15 of 20: Please send us a clear image of your hair line at the front (forehead).

Hairline at the front *

Click or drag files to this area to upload. You can upload up to 3 files.

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Question 16 of 20: Please send us a clear image of your hair from the top, or any areas of loss

Hair loss additional area

Click or drag files to this area to upload. You can upload up to 3 files.

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Question 17 of 20: Please send us a clear picture of your photographic ID (drivers license, passport, picture of you holding a utility bill)

Photographic ID *

Click or drag files to this area to upload. You can upload up to 3 files.

I acknowledge and agree that I have completed a medical intake form to be reviewed – to create my medical treatment plan. I confirm that I understand all the questions asked, that the information I provided is accurate and complete, and that I am the patient consenting to be evaluated for treatment via telehealth or other means. *

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Question 18 of 20: Licensed and unlicensed medicines. On the UK market there are some preparations licensed to treat medical grade hair loss. SiloxysSystem – the advanced absorption vehicle incorporated into our products is compounded in a medicine specifically for you based on the needs you have identified. This means the medicine will be personalised, but will not carry a product license and therefore is “unlicensed” under UK law. The medicines used include finasteride, duasteride and minoxodil. Furthermore, the medicines used – although safe for humans are not safe when they come in contact with domestic pets – before treatment care must be taken to make sure cats and dogs do not come into contact with these medicines directly, or indirectly (for example licking treated areas or fingers).

I understand this statement and will comply with all instructions for use *

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Question 19 of 20: By submitting this form I formally allow Xyon, Dickson Chemist (their provider in the UK) and the manufacturers of the medicine to process my data in order to provide a consultation for hair loss.

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Question 20 of 20: This is not an NHS service. This is a private medical service which must be paid for. The medicines start at £75 and depending on what is deemed most appropriate during the consultation may be higher. I understand this is a joint decision between myself and the prescribing consultant.

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