Assessment Form for Vaniqa Cream

Section 1: Personal details

Full name:

Email address:

Contact number:

Section 2: Eligibility Questions

Are you a woman aged 19 or over?
YesNo

(Vaniqa is licensed for women aged 19+)

Do you suffer from unwanted facial hair?
YesNo

Which areas are affected? (select all that apply)
Upper lipChinJawline/sideburn areaOther

Section 3: Medical History

Are you allergic to eflornithine or any ingredients in this cream?
YesNo

Do you suffer from any of the following conditions?
Polycystic ovary syndrome (PCOS)Cushing's syndromeCongenital adrenal hyperplasiaAndrogen-secreting tumour of the ovaries or adrenal glandKidney problemsLiver problemsNone of the aboveOther

Are you pregnant, planning pregnancy, or breastfeeding?
YesNo

Section 4. Medications

Are you taking any of the following medications? (select all that apply)
GlucocorticoidsMinoxidilHormone Replacement TherapyPhenobarbitone or phenytoinCyclosporineNone of the above

Are you taking any other medication not mentioned above?
NoYes

Section 5: Declaration & Consent

I confirm that the information I have provided is complete and accurate to the best of my knowledge.

I consent to Batley Pharmacy contacting me with personalised treatment and follow-up advice.

I understand that Vaniqa will not remove hair completely but will slow regrowth; I have read the provided product information.