Minoxidil Shampoo Refill Form

Minoxidil Shampoo REFILL 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 and includes Minoxidil Shampoo refill prescriptions good for 12 months.   Combining topical minoxidil 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. Male pattern hair loss is a life-long condition and you need to continue to use Minoxidil to halt the natural progression of Male pattern baldness and to prevent the new hair regrowth from thinning out.

Please fill in all fields and respond to all questions honestly and completely. 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.)consultation.

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.

NOT  AVAILABLE IN ILLINOIS AND ARKANSAS AND FLORIDA

Minoxidil Shampoo prescriptions are compounded by Trinova Health**. If you have any questions regarding pricing or shipping, contact Trinova Health directly at 813-551-1165. There are NO refunds for consultations if the pharmacy cannot ship to your location.

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

MEDICAL HISTORY

Sex
Did you experience any side effects:

Detail your progress:  how long before you started to notice changes, if you had any initial shedding, thickening of hair, regrowth etc.

Are you combining Topical Minoxidil treatment with any other treatments for Male Pattern Hair Loss?
Have there been any changes in your current medical conditions that the consulting Physician should be aware of?

Do you take any prescription medication?
Do you have any known allergies to Medicines?
Have you had a physical exam in the last two years?

Do you suffer from Male Pattern Hairloss?
Do you have or are you being treated for glaucoma - increased intraoccular eye pressure
Are you allergic to Rogaine?
Are you allergic to steroids, corticosteroids, hydrocortisone?
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?
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 on Chemotherapy or being treated for cancer?
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
Was your hair loss
Is your hairloss due to the side effect of medication or chemotherapy or nutritional disease or thyroid disease?
Is your hairloss due to chemical treatment of your hair - perms? relaxing? coloring? or from hairstyle such as cornrowing? ponytail?

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
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.)


BY SUBMITTING THIS CONSULTATION FORM, 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 Hairloss 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 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 , Trinova Health,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.
  • 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.

Prescriptions forwarded to Trinova Health compounding pharmacy.

Medical Wellness Center only bills you for the consultation service.   We do not sell or dispense medication.  Your prescription is forwarded to Trinova Health and the pharmacy ships the medication to you.   For pricing or whether the pharmacy ships to your location contact Trinova Health:   Phone  813-551-1164 or Email -  contact@trinovahealth.com

Choose Regular or Express Processing: *

For refill prescriptions you have the option of:

1.  REGULAR SERVICE:  Your prescription is forwarded to Trinova Health in 3- 7 days.  Regular service processing fee is $9.50.

2.  EXPRESS SERVICE: Or you can select Express 24 hour processing, and your prescription will be faxed to Trinova Health in approximately 24 hours.  If you select Express 24 hour processing, you will be charged a $20 express processing fee rather than the regular processing fee of $9.50.

Please confirm whether you are choosing Regular or Express Service:

**Medical Wellness Center is not affiliated or associated with Trinova Health.   Trinova Health 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 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.

Click SUBMIT button (secure server) to order Minoxidil Shampoo Refill Consultation

For any questions and fastest reply contact us by

email at wellnessmd@medicalwellnesscenter.com

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