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.

Minoxidil Shampoo Refill Form