Minoxidil Refill Form Minoxidil REFILL Form Fields marked with an * are required HTML Welcome back. After your initial Minoxidil consultation approval, each follow-up consultation, if approved, is only $75 (plus processing). The refill consultation includes customized Minoxidil 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 minoxidil 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 and you need to continue to use customized Minoxidil formulations to halt the natural progression of Male pattern baldness and to prevent the new hair regrowth from thinning out. HTML NOT AVAILABLE IN ILLINOIS AND ARKANSAS AND FLORIDA 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: * Medical Wellness Center Membership Number Date of Birth (MM/DD/YY) * Age Sex Male Female Height: Weight: Please describe your treatment regimen: which products prescribed from Medical Wellness Center using, how often and when you applied the product - mornings or evenings etc. Did you experience any side effects: Yes No If yes, have these symptoms resolved? If not, please describe symptoms: Describe your response to customized MINOXIDIL treatment and detail the progress. Are you combining Topical Minoxidil treatment with any other treatments for Male Pattern Hair Loss? Yes No If yes, list other treatments both topical and systemic: 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: 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 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 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 $75.00 (plus S&P $9.50 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 $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 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 **** The prescription is only valid in the United States. Medical Wellness Center does not prescribe and Trinova Health does not ship out of the United StatesNOT AVAILABLE IN ILLINOIS AND ARKANSAS AND FLORIDAYour prescription for your compounded topical Minoxidil preparation will be forwarded to Trinova Health Compounding pharmacy. Trinova Health Pharmacy (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 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, Biotin, Ketoconazole, Latanoprost, Finasteride, 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 Compounding pharmacy For pricing you need to contact Trinova Health 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% Latanoprost 0.01% 0.1% Hydrocortisone (Do not add if have glaucoma or allergic/sensitive to steroids) List Below any Additional customization HTML All formulations contain Propylene Glycol. If you are allergic to Propylene Glycol, ask your local compounding pharmacy if glycerin may be substituted at an additional cost Are You Allergic to Propylene Glycol? Yes No Divider Additional Comments: Divider TRINOVA HEALTH compounding pharmacy The prescription can only be forwarded and filled at Trinova Health Compounding pharmacy for reliability and consistency of the compounded formulation HTML 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 consultation. Consultation reviewed in 3 - 7 days and forwarded to Trinova Health compounding pharmacyExpress Service - $75.00 consultation fee plus $20 express fee. Consultation reviewed and your prescription forwarded 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 HTML Click SUBMIT button (secure server) to order Minoxidil Refill 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.
