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I agree that all information that I have given is true to the best of my knowledge and that I have not withheld information that could potentially be deemed relevant to a doctor's decision to prescribe medicines for hair loss. I agree that only I, the named patient completing this questionnaire, will take any medicines that I may be prescribed following submission of this form. I agree, prior to taking any medicines that may be prescribed, to read the patient information leaflet supplied with the medicines, and adhere to the instructions that accompany the medicines that I am requesting. I understand that there is a small chance of side effects that can occur from the hair loss medications offered by Advanced Hair Studio. The most common or relevant side effects related to the medicine or medicines that are prescribed to me should be explained by the adviser that contacts me, but should I have any further queries I will ask. I agree to notify Advanced Hair Studio if any side effects occur.