Winlevi (Clascoterone) Hair Loss REFILL Consultation Form
Fields marked with an * are required

Welcome back. After your initial consultation approval each follow-up consultation, if approved, is only $75 plus processing.  The refill consult includes a Winlevi (clascoterone) 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 a topical DHT androgen-receptor inhibitor 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 Winlevi (clascoterone) 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:

Click here to read the stated contraindications before filling out the medical consultation form:

NOT AVAILABLE IN ILLINOIS , ARKANSAS, and  FLORIDA

The medical information you supply is subject to ALL patient/doctor privilege laws.

MEDICAL HISTORY
Sex

List which products prescribed from Medical Wellness Center using, how often and when you applied the product - mornings or evenings etc.

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:
Have there been any changes in your current medical conditions that the consulting Physician should be aware of?
Do you take any prescription medication?

For example: Avodart -3 years, Minoxidil 2 yrs, Zoloft- 6mo, etc.

For example: aspirin -for migraines, Unisom -difficulty sleeping etc.
Do you take Oral Aldactone or Oral Spironolactone?
Do you use Topical Spironolactone?
Do you have a prescription for Propecia or Avodart?
Do you use Minoxidil or Latisse or Nizoral Shampoo?
Are you using any other treatments for Male Pattern Hair Loss?
Do you have any known allergies to Medicines?
Have you had a physical exam in the last two years?
Are you allergic to Winlevi (clascoterone) or any of the ingredients in Winlevi cream?
Have you ever been diagnosed in the past with Addison's disease or adrenal insufficiency?
Are you currently taking oral Spironolactone or Aldactone?
Are you currently pregnant or nursing?
Are you currently being treated for cancer?
Do you smoke?
How much alcoholic beverages do you drink?

CURRENT MEDICAL CONDITIONS & PAST MEDICAL HISTORY
Do you have or have you ever had any of the following conditions?
Are you currently taking steroids?
Have you had surgery in the last 3 months?

FAMILY HISTORY
Does Male Pattern Hair Loss run in your family?
Do any of your immediate family members have any of the following medical problems?

HAIR LOSS HISTORY
Do you suffer from Male Pattern Baldness?
Have you been treated before for hair loss?
Check each treatment that you have undergone:
Are you experiencing SUDDEN hair loss unrelated to male pattern hair loss?
Is your hair loss due to the side effect of medication or chemotherapy or nutritional disease or thyroid disease?
Is your Hair loss due to chemical treatment of your hair - perms? relaxing? coloring? or from hairstyle such as cornrowing? ponytail?
Are you using any other medicines on your scalp?
Do you have any skin conditions on your scalp such as eczema, psoriasis, red inflamed painful scalp conditions?

Please from the illustration description below, choose which Norwood Classification of Hair Loss best describes your present condition: 


Please select your current Norwood Classification:

PERSONAL AND PAYMENT INFORMATION
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
Credit Card Type

This is commonly found on the back of your debit/credit card.  Am Exp may be 4 digits
Credit Card Verification

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.)

AVAILABLE IN UNITED STATES ONLY 
Services not available in Arkansas, Illinois, or Florida

You can choose either to receive a written prescription by mail which you can fill at your local United States pharmacy, or to have your prescription called into your local United States pharmacy.  The prescription can not be filled at an internet pharmacy such as Amazon.com  or .COM version of a local pharmacy, or at a foreign or Canadian pharmacy

Medical Wellness Center does not sell or dispense any medications and we are not affiliated with any pharmacies.  For pricing and price comparisons, you need to contact the pharmacy directly. Winlevi is NEW and very expensive, check first with your pharmacy for pricing.  It is not covered by insurance because it is for cosmetic hair loss
1. First, choose ONE of the two choices below: *

Choose whether you want to receive written prescription or prescription called into local pharmacy:


1. RECEIVE WRITTEN PRESCRIPTION: Receive Written prescription in approximately 7- 15 days which you can fill at most any local, brick and mortar, United States pharmacy of your choice. (NOT available in CA, NY, MA, VT, RI, CT and IN)

2. PRESCRIPTION CALLED INTO LOCAL PHARMACY: Prescription for one year of refills called into most any major local, brick and mortar, United States pharmacy of your choice rather than receiving a written prescription by mail. If approved, your prescription will be called into a pharmacy of your choice. There is no extra charge for this service for refill prescriptions (unless you are choosing the Express Refill call in service) Your credit card will be billed the $75 consultation fee and regular processing fee of $ 9.50. If you are requesting your prescription to be called into your pharmacy, you will need to enter the complete phone# including area code, name and address of pharmacy where you choose to fill your prescription.

The prescription can only be called into your local United States pharmacy. It can not be called in, faxed or filled at an internet pharmacy, foreign pharmacy, Canadian pharmacy or pharmacies such as Drugstore.com or Amazon.com or an internet version of a local pharmacy such as CVS.com or Costco.com etc. 

If you selected RECEIVE WRITTEN Prescription to fill at your local California, New York, Massachusetts, Vermont, Rhode Island, Connecticut, or Indiana pharmacy, the prescription has to be ePrescribed.  These states, CA, NY, MA, VT, RI, CT, and IN,  will not accept written prescriptions.  Please enter the NAME, ADDRESS and Phone number of your local California, New York, Massachusetts, Vermont, Rhode Island, Connecticut, or Indiana pharmacy.
REGULAR Service your consult will be processed in 3-7 business days.  EXPRESS Service in approximately 24 hours.
2. Next, Choose Regular or Express Service: *

After making the above selection, select whether you want 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 either, called into local pharmacy, or receive written prescription in 7-15 days (written prescription not available in CA, NY, MA, VT, RI, CT and IN) .

    Express Service - $75.00 consultation fee plus $20 express fee.  Consultation reviewed and your prescription either called into or Eprescribed to your local pharmacy  within approximately 24 hours.

    BY SUBMITTING THIS CONSULTATION FORM, 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 Winlevi (clascoterone) is not to be used by anyone under the age of 18.
    • I understand that Winlevi (clascoterone) 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 Winlevi (clascoterone) is NOT to be used by pregnant or nursing woman.
    • I am aware that I need to inform my doctor that I am using Winlevi (clascoterone)
    • 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 my selected pharmacy directly. 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 check first with your pharmacy for pricing.  Winlevi is NEW and very expensive.
    • 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.
    Please CONFIRM YOUR SELECTION made above: *

    Click SUBMIT button (secure server) to order Winlevi (Clascoterone) Refill Consultation

    For any questions and fastest reply contact us by

    email at wellnessmd@medicalwellnesscenter.com

    Phone (United States Only):  617-367-8887