Minoxidil INITIAL Consultation Form Fields marked with an * are required HTML Please fill in all fields and respond to all questions honestly and completely so that a physician can review your consultation. If approved, your Minoxidil prescription will be forwarded to Trinova Health compounding pharmacy with six additional refills. You will receive a confirmation email after approved. If the consulting physician determines Minoxidil is not appropriate for you, there is NO charge for this consultation. **If on ORAL Minoxidil, we offer a Minoxidil-FREE lotion with 5% Azeleic Acid, 0.25% Progesterone, 0.025% Retinoic Acid, 0.1% Hydrocortisone with or without 0.1% Finasteride. HTML NOT AVAILABLE IN ILLINOIS AND ARKANSAS AND FLORIDA This service is only available in the United States. Trinova Health Pharmacy does not prescribe out of the United States. I have read the previous Minoxidil 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 The medical information you supply is subject to ALL patient/doctor privilege laws. Divider HTML MEDICAL HISTORY First and Last Name: * Date of Birth (MM/DD/YY) * Age Sex Male Female Height: Weight: Divider 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: Do you currently take Oral Propecia or Proscar (finasteride) or use topical finasteride? * Yes No Do you currently take oral Avodart or dutasteride? * Yes No Are you planning to combine Topical Minoxidil treatment with any other treatments for Male Pattern Hair Loss? Yes No If yes, list other treatments both topical and systemic: Please list all over-the-counter drugs you take regularly and why. 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 Do you suffer from Male Pattern Hairloss? Yes No Do you have or are you being treated for glaucoma - increased intraoccular eye pressure Yes No Are you allergic to Rogaine? Yes No Are you allergic to steroids, corticosteroids, hydrocortisone? Yes No 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: 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? Glaucoma Scalp Eczema Scalp Psoriasis Scalp Skin Disease Coronary Artery Disease High Blood Pressure Thyroid disease gallbladder disease Cirrhosis of Liver Kidney Disease Enlarged Prostate Heart Attack Stroke Depression Liver Disease Hepatitis Prostate problems Elevated PSA Levels Heart disease Diabetes Endocrine Disorders None of the Above Are you currently on Chemotherapy treatment for cancer? 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 Prostate Cancer Liver Disease Heart disease Gallbladder disease Benign Prostate Enlargement Stroke Arteriosclerosis Cancer 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 Avodart Surgical Other If other please list At what age did you first notice hair thinning? Was your hair loss Sudden not due to Male Pattern Hair Loss Gradual 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 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 BY SUBMITTING THIS CONSULTATION FORM, I CERTIFY: I Certify I am a male 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 MWC does not prescribe Minoxidil to anyone under age 18.I understand MWC does NOT prescribe Minoxidil Online to Women as Male Pattern Hair loss can be a sign of serious and life-threatening underlying disease and even cancer in women.I understand must NOT use Minoxidil if have scalp conditions or irritations such as scalp eczema or psoriasis or sunburn.I do not have any of the contraindications to therapy.I do not have a current prescription for Minoxidil from another physician and I do NOT have or use any other prescription medications on my scalp.I understand that my credit card will be billed $49.95 (plus S&P $10.35 or $20 Express Processing) 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 $49.95 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 use the medication or I am advised not to use 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. Also, if the pharmacy refuses to fill a valid prescription issued by Medical Wellness Center due to do 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. Divider HTML **** Trinova Health Compounding pharmacy does not ship out of the United States NOT AVAILABLE IN ILLINOIS AND ARKANSAS AND FLORIDA Your prescription for your compounded topical Minoxidil preparation will be forwarded to Trinova Health Compounding pharmacy. Trinova Health (813-551-1165) is a compounding pharmacy and they will contact you directly by email and or phone for your payment and shipping information. You can customize your minoxidil formulation by choosing the strength and additives. If you have glaucoma or are sensitive to steroids, do NOT select hydrocortisone additive. Minoxidil is available ONLY in these formulations:5% Spray Liquid in a glycerin base with 5% Azelaic Acid and 0.1% finasteride is the only additive choices 5% Minoxidil Lotion12.5% Minoxidil Lotion 15% Minoxidil Lotion or Cream30% Minoxidil Cream Only Additive Choices: Tretinoin, Azelaic Acid, Retinoic Acid, Progesterone, Finasteride 0.1%, Biotin 0.25%, Ketoconazole 2%, Latanoprost 0.01%, Hydrocortisone (IF YOU HAVE GLAUCOMA OR ARE SENSITIVE TO STEROIDS DO NOT SELECT 1% Hydrocortisone)**All lotions and creams are compounded with DMI and Vit E in propylene glycol, if you are allergic to propylene glycol make sure to request a different formula compounded in glycerin instead. Medical Wellness Center is a physician consulting service and does not sell or dispense medication. Our preferred compounding provider is Trinova Health Pharmacy. For pricing you need to contact Trinova Health pharmacy directly at 813-551-1165 1.First, indicate your choice of Minoxidil strength: * 5% Minoxidil Lotion 12.5 % Minoxidil Lotion 15% Minoxidil Lotion 15% Minoxidil Lotion (Propylene-glycol free Glycerin Base) 15% Minoxidil Cream 30% Minoxidil Cream If on ORAL Minoxidil, Minoxidil-FREE LOTION 2. Next, indicate your choices of optional additives to the above selected Minoxidil Strength. * No additional Additives 5% Azelaic Acid 0.025% Tretinoic (Retinoic Acid) .25% Progesterone Biotin 0.25% Ketoconazole 2% ( do not add if on oral or topical ketoconazole) Latanoprost 0.01% 0.1% Hydrocortisone (Do not add if have glaucoma or allergic/sensitive to steroids) HTML All formulations contain Propylene Glycol. If you are allergic to Propylene Glycol,glycerin may be substituted at an additional cost Are You Allergic to Propylene Glycol? Yes No Additional comments: Divider HTML In addition, for one consultation fee, you can also choose to receive prescriptions for any or all of the following compounded formulas: 5% Minoxidil Spray with your choice of additives 5% Minoxidil Shampoo (no additives) Acetyl Glutathione hair maturation enhancer with 3% Biotin Check below the additional prescriptions you would like to add: 5% MINOXIDIL SPRAY with 5% Azelaic Acid in glycerin base or 5% MINOXIDIL SPRAY with 5% Azelaic Acid + 0.1% FINASTERIDE in glycerin base 5% MINOXIDIL SHAMPOO (no additives) Acetyl Glutathione + 3% Biotin in Propanediol solution We only offer a 5% minoxidil spray due to the limited solubility of Minoxidil and the decreased stability of the solutions. In order to keep USP standard minoxidil in solution at higher strengths, you have to add some pretty strong acids (phosphoric, sulfuric). Also, if you check your bottle from other pharmacies, you will notice it's in a dark bottle and it will have an alcohol smell when you spray it. Most of the ingredients are settled to the bottom and are not in solution. HTML Acetyl Glutathione is a topical enhancer which comes in a 30 ml size dropper bottle. Acetyl Glutathione is the body's only naturally manufactured antioxidant. This ingredient MATURES the hair, unlike the biotinoyl tripeptide which only causes immature hairs to grow and NOT mature. This Acetyl Glutathione is compounded with 3% Biotin in a Propanediol base. Specifically, the Biotin promotes growth of immature hairs and the Acetyl Glutathione promotes the maturation of the hair follicle. Additional Comments: Divider HTML Select whether you want REGULAR or EXPRESS SERVICE:Regular service - $49.95 consultation fee plus $10.30 processing fee to Medical Wellness Center for the online doctor consultation. Consultation reviewed in 3 - 7 days and faxed to Trinova Health Compounding Pharmacy.Express Service - $49.95 consultation fee plus $20 express fee. Consultation reviewed and your prescription faxed to Trinova Health Compounding Pharmacy. within approximately 24 hours. Please check here if your are selecting EXPRESS 24 hours service - $20 express processing fee Please confirm whether you are choosing Regular or Express Service: * REGULAR SERVICE EXPRESS SERVICE Prescription Choice Confirmation * Topical Minoxidil 5% - 30% lotion or cream with optional additives (Similar to Dr. Klein's formulations) 5% Minoxidil spray with 5% Azelaic acid and optional finasteride additive 5% Minoxidil Shampoo with no additives Acetyl Glutathione with 3% biotin Minoxidil-FREE Topical Lotion-if on ORAL Minoxidil Confirm you selections of Topical Hair Loss formulations selected above: Referral Source Former Dr. Klein Patient Referred by Jazz Referred from a Chat Room or Blog Other How did you learn about our Minoxidil Website? Please list Chat Room or Blog or Other Source you learned about Medical Wellness Center compounded hair loss formulations HTML **Medical Wellness Center is not affiliated or associated with Trinova Health Compounding 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 almost 20 years experience treating male pattern hair loss, and they forward all compounded hair loss prescriptions exclusively to Trinova Health Compounding pharmacy because of the integrity and reliability of this United States based, privately owned, local pharmacy and this pharmacy only uses FDA approved ingredients. HTML Click SUBMIT button (secure server) to order Minoxidil Initial Consultation For any questions and fastest reply contact us by email at wellnessmd@medicalwellnesscenter.comPhone (United States Only): 617-367-8887 If you are a human seeing this field, please leave it empty.
