Topical Spironolactone Refill Form Topical Spironolactone REFILL Form Fields marked with an * are required HTML Welcome back. After your initial consultation approval each follow-up consultation, if approved, is only $75 plus processing. The refill consult includes a Topical Spironolactone refill prescriptions good for 12 months. Hair growth is very slow and it may take up to a year to notice the full benefits. Combining topical formulations with a systemic 5-alpha reductase inhibitor such as Propecia or Avodart can enhance the effectiveness of both treatments and maximize hair thickening and regrowth. After the first three months of treatment you may start to notice some improvement. But,for some, improvements are not noticed until six months or longer. Male pattern hair loss is a life-long condition. Therefore, you need to continue with your treatment regimen to halt the natural progression of Male pattern baldness and to prevent the new hair regrowth from thinning out. Please accurately and completely provide the following information in order for a physician to review your record. You must include your Medical Wellness Center Membership Number which was assigned upon approval into the program. (If you don't have this available, you can Email us for your membership number.) I have read the previous Topical Spironolactone pages and I do NOT have any of the stated contraindications. I understand the WARNINGS and I have read and agree to the Waiver of Liability: Yes No Click here to read the stated conditions before filling out the medical consultation form: HTML NOT AVAILABLE IN ILLINOIS , ARKANSAS, and FLORIDA HTML Topical Spironolactone is available in 2% or 5% solutions, lotions, or creams. For quality assurance and consistency of the compounded formula, we fax compounded topical spironolactone prescriptions to Trinova Health Compounding pharmacy. HTML The medical information you supply is subject to ALL patient/doctor privilege laws. Divider HTML MEDICAL HISTORY First and Last Name: * Medical Wellness Center Membership Number Date of Birth (MM/DD/YY) * Age Sex Male Female Height: Weight: Divider Please describe your hair loss treatment regimen: List which products prescribed from Medical Wellness Center using, how often and when you applied the product - mornings or evenings etc. Describe your response to Topical Spironolactone treatment: Detail your progress and how long before you started to notice changes, if you had any initial shedding, thickening of hair, regrowth etc. Did you experience any side effects: Yes No If yes, have these symptoms resolved? If not, please describe symptoms: Have there been any changes in your current medical conditions that the consulting Physician should be aware of? Yes No If yes, be sure to also consult you regular primary care physician, symptoms could be unrelated to current treatment and related to some other condition Please list all current medical conditions: Do you take any prescription medication? Yes No If YES, please list all Prescription Medications you are currently taking and the length of time taking each of them: Please list all over-the-counter drugs you take regularly and why. Do you take Oral Aldactone or Oral Spironolactone Yes No Do you have a prescription for Propecia or Avodart? Yes No Do you use Minoxidil or Latisse or Nizoral Shampoo? Yes No Are you using any other treatments for Male Pattern Hair Loss? Yes No If yes, list other treatments both topical and systemic: Do you have any known allergies to Medicines? Yes No If Yes, please list any known Allergies to Medicines: Have you had a physical exam in the last two years? Yes No Divider Are you allergic to Spironolactone or any of the ingredients in Topical Spironolactone? Yes No Have you ever been diagnosed in the past with Kidney disease, Hyperkalemia (high potassium) or Addison's disease? Yes No If yes, please detail and explain diagnosis: Are you currently taking oral Spironolactone or Aldactone? Yes No Are you currently pregnant or nursing? Yes No Are you currently being treated for cancer? Yes No If yes, please explain Do you smoke? Yes No How much alcoholic beverages do you drink? None Occasionally Moderately Heavily Divider HTML CURRENT MEDICAL CONDITIONS & PAST MEDICAL HISTORY Do you have or have you ever had any of the following conditions? Hyperkalemia (high potassium) Jaundice Coronary Artery Disease High Blood Pressure Scalp Eczema Thyroid disease Addison's Disease Kidney Disease Heart Attack Stroke Scalp Psoriasis Depression Liver Disease Eye Pressure Problems Diabetes Scalp Skin Disease None of the Above Are you currently taking steroids? Yes No Have you had surgery in the last 3 months? Yes No If yes please explain Do you consider anything in your medical history to be relevant, please give details. If unsure, please ask your regular doctor Divider HTML FAMILY HISTORY Does Male Pattern Hair Loss run in your family? Yes No Do any of your immediate family members have any of the following medical problems? Diabetes High blood pressure Kidney Disease Addison's Disease Prostate Cancer Liver Disease Heart disease Gallbladder disease Stroke Arteriosclerosis Cancer Glaucoma Male Baldness None of the Above Are there any other diseases than run in your family? Divider HTML HAIR LOSS HISTORY Do you suffer from Male Pattern Baldness? Yes No Have you been treated before for hair loss? Yes No Check each treatment that you have undergone: None Rogaine/minoxidil Propecia (finasteride) Avodart (dutasteride) Latisse Nizoral Shampoo Surgical Other If other please list At what age did you first notice hair thinning? Are you experiencing SUDDEN hair loss unrelated to male pattern hair loss? Yes No Is your hair loss due to the side effect of medication or chemotherapy or nutritional disease or thyroid disease? Yes No Is your Hair loss due to chemical treatment of your hair - perms? relaxing? coloring? or from hairstyle such as cornrowing? ponytail? Yes No Are you using any other medicines on your scalp? Yes No If yes, please explain: Do you have any skin conditions on your scalp such as eczema, psoriasis, red inflamed painful scalp conditions? Yes No If yes, please explain: Please describe your history of hair loss: HTML Please from the illustration description below, choose which Norwood Classification of Hair Loss best describes your present condition: Please select your current Norwood Classification: Class 2: Receding Hairline Class 3: Generalized Frontal Thinning Class 4: Frontal Area & Crown Balding Class 5: Top of Scalp & Crown Balding Class 6: Extensive Hair Loss Class 7: Severe Hair Loss Only rim of hair remains Divider HTML PERSONAL AND PAYMENT INFORMATION HTML In order to review your consultation, you must provide your full name, a Physical Address (We do NOT accept requests to PO Boxes) and complete Phone number. We do NOT accept requests from Illinois or Arkansas or Florida Full Name ADDRESS: City State Zip Code Country Phone * Email * Name of Credit Card Holder Credit Card Type Discover Mastercard Visa Credit Card Number * Expiration Date (MM/YY) * 3 Digit Security Code * BILLING ADDRESS: Billing Zip Code Credit Card Verification Yes No I, AS THE CREDIT CARD HOLDER, VERIFY THAT I AM SUBMITTING THIS ONLINE-CONSULTATION REQUEST FOR A MEDICAL PRESCRIPTION AND I AUTHORIZE THE CHARGES STATED TO BE MADE TO MY CREDIT CARD (I understand that if I later dispute this charge as "unauthorized" I will be subject to criminal prosecution for credit card fraud). If credit card holder name is different than the person submitting consultation, you must verify that you have been given authorization to use this credit card: I VERIFY THAT I HAVE BEEN GIVEN AUTHORIZATION BY CREDIT CARD HOLDER TO USE ABOVE CREDIT CARD.( I understand that if this charge is disputed by credit card holder as unauthorized, I will be subject to penalties of criminal prosecution for credit card fraud.) Divider HTML AVAILABLE IN UNITED STATES ONLY Services not available in Arkansas, Illinois, or Florida Your prescription for your compounded Topical Spironolactone formulation, with 11 additional refills valid for one year, will be forwarded Trinova Health Compounding pharmacy. The pharmacy will contact your by phone and or email for your payment and shipping information. Medical Wellness Center is a physician consulting service and does not sell or dispense medication. For pricing, shipping costs and whether they can ship to your destination if out of the United States, you need to contact Trinova Health directly, phone 813-551-1165Indicate your choice below of Topical Spironolactone strength and formulation: Select Topical Spironolactone Prescription Strength and Formulation * 65ml 2% Spironolactone alcohol SOLUTION 65ml 2% Spironolactone LOTION 60gm 2% Spironolactone CREAM 65ml 5% Spironolactone SOLUTION 65ml 5% Spironolactone LOTION 60gm 5% Spironolactone CREAM Choose Regular or Express Service: * REGULAR SERVICE EXPRESS SERVICE 2. Next after making the above selection, select whether you REGULAR or EXPRESS SERVICE:Regular service - $75.00 consultation fee plus $9.50 processing fee to Medical Wellness Center for the online doctor visit. Consultation reviewed in 3 - 7 business days and forwarded to Trinova Health Compounding Pharmacy.Express Service - $75.00 consultation fee plus $20 express fee. Consultation reviewed and your prescription forwarded to Trinova Health compounding pharmacy within approximately 24 hours. If you selected EXPRESS Service above, please check here to confirm Express Service Divider HTML BY SUBMITTING THIS CONSULTATION FORM, I CERTIFY: I Certify 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 SpironolactoneI do not have any of the contraindications to therapy.I am not currently taking Aldactone or Oral SpironolactoneI 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. HTML *Medical Wellness Center is not affiliated or associated with any pharmacy. HTML Click SUBMIT button (secure server) to order Topical Spironolactone Refill Consultation For any questions and fastest reply contact us by email at wellnessmd@medicalwellnesscenter.comPhone (United States Only): 617-367-8887 HTML *Medical Wellness Center is not affiliated or associated with Trinova Health Pharmacy. Trinova Health Compounding pharmacy is a privately owned pharmacy and is completely independent of Medical Wellness Center. Medical Wellness Center provides customized treatments based on over 20 years experience treating male pattern hair loss. We forward compounded hair loss prescriptions to Trinova Health because of the integrity and reliability of this United States based, privately owned, local pharmacy, and that this pharmacy only uses FDA approved ingredients. If you are a human seeing this field, please leave it empty.
