To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.

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Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.

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Face
Chest
Abdomen
Lower Back
Upper Arms
Thighs
Other






Select all that apply.
Sudden rapid excess hair growth
Sudden weight gain
particularly in your face
upper back and shoulders
Unexplained stretch marks on your skin
Bruising easily
Deepening of your voice
Your hands and feet getting bigger
Muscle weakness
A mass in your abdomen
None of the above

Select all that apply.
Thyroid problems
Acne
Polycystic Ovary Syndrome
Problems with your adrenal gland (including in your family)
Problems with your hormone levels (such as high levels of prolactin
testosterone or progesterone)
Acromegaly
Any type of cancer
Acanthosis nigricans
Porphyria
An eating disorder (such as anorexia nervosa)
Severe head injury
Epidermolysis bullosa
Dermatomyositis
None of the above



- You understand that Vaniqa is specifically prescribed for women with unwanted facial hair (hirsutism).

- You understand the application instructions and frequency of use as directed by your healthcare provider.

- You acknowledge that Vaniqa may take several weeks to show visible results, and continuous use is necessary for sustained effects.

- You understand that Vaniqa is for external use only and should not be applied to irritated or broken skin.

- You understand and will follow any additional instructions provided by your healthcare provider regarding the use of Vaniqa.





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- I am between the ages of 18 and 75

- This treatment is for my use only

- I have the capacity to make decisions about my own healthcare

- I have understood all the questions and have answered this consultation truthfully and completely

- I understand the prescriber will use my answers and base their prescribing decisions accordingly, and that providing incorrect information could be harmful to my health

- I will read the patient information leaflet supplied with this medication

- I will contact we prescribe and inform my GP if I experience any side effects from this treatment or if there are any changes to my health

- I have read, understood and agree with our Terms and Conditions