I am 18 years of age or older.
I have read and agree to Waiver of Liability.
I understand the side effects of this medication and adverse effect.
I understand that Topical Spironolactone is not to be used by anyone under the age of 18.
I understand that Topical Spironolactone is NOT prescribed to women for hair thinning because women's hair loss or thinning can be due to an underlying life threatening medical condition and needs direct physician monitoring.
I understand that Topical Spironolactone is NOT to be used by pregnant or nursing woman.
I am aware that I need to inform my doctor that I am using Topical Spironolactone
I do not have any of the contraindications to therapy.
I am not currently taking Aldactone or Oral Spironolactone
I understand that my credit card will be billed $75.00 (plus S and P $9.50 or $20 for Express service) for the medical consultation if approved, if not approved there is no charge for the consultation. If approved I understand I am not purchasing medication from Medical Wellness Center but rather the online consultation service. I purchase the medication from the compounding pharmacy where the prescription is forwarded and filled. I understand that by submitting this form it's an "electronic signature" of a binding agreement that I agree to pay the $75.00 consultation fee plus S & P if approved and understand that there are no refunds for any circumstances even if I later change my mind and decide not to fill the prescription or take the medication or I am advised not to take this medication by another physician. I understand that whether I choose to fill the prescription or not or whether I change my mind and decide not to take the medication, there are absolutely NO refunds for the online consultation fee. It is YOUR responsibility to make sure that your local compounding pharmacy can compound Topical Spironolactone. Also, if the pharmacy refuses to fill a valid prescription issued by Medical Wellness Center due to failure to verify your billing/shipping or Credit card information that you provided to the pharmacy or failure of your payment authorization to them we do NOT refund the consultation fee.
I have answered all the questions truthfully and I understand that by clicking submit I agree to all the terms and conditions including that my credit card will be charged the above stated amount for the consultation if approved.

Topical Spironolactone Refill Form