Topical Spironolactone Online Prescription for Male Pattern hairloss

Topical Spironolactone Prescription for Male Pattern Hair Loss Consultation FORM


Please fill in all fields and respond to all questions honestly and completely so that a physician can review your consultation and prescribe Topical Spironolactone if approved. If approved your prescription will be forwarded to Trinova Health pharmacy with 6 additional refills. We do NOT sell or ship medication. If the consulting physician determines that Topical Spironolactone is not appropriate for you, there is NO charge for this consultation. Topical Spironolactone is only available in the following strengths and formulations compounded by Trinova Health pharmacy: 2% Compounded Topical Spironolactone 65ml 2% Spironolactone alcohol SOLUTION 65ml 2% Spironolactone LOTION 60gm 2% Spironolactone CREAM 5% Compounded Topical Spironolactone 65ml 5% Spironolactone alcohol SOLUTION 65ml 5% Spironolactone LOTION 60gm 5% Spironolactone CREAM Choices: Regular Service: Consultation is reviewed in approximately 3 - 7 business days Express Service: Your consultation is reviewed and your prescription is forwarded to Trinova Health pharmacy in approximately 24 hours or less NOT AVAILABLE IN ILLINOIS , ARKANSAS, and FLORIDA Click here to read the stated conditions before filling out the medical consultation form:** I have read the previous Topical Spironolactone 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
*The medical information you supply is subject to ALL patient/doctor privilege laws.*

**MEDICAL HISTORY**
First and Last Name: SEX: Female Male Date of Birth(MM/DD/YY): Current Age: Height (inches):Weight: Do you have a prescription from Medical Wellness Center for Propecia or Avodart or Minoxidil or Latisse or Nizoral Shampoo?YESNO If yes, enter Medical Wellness Center Membership Number:


Please list all current Medical Conditions: Do you take any prescription medication or take oral Aldactone or oral Spironolactone?YESNO If YES, please list all Prescription Medications you are currently taking and the length of time taking each of them: For example: Claritin -4yrs; Zoloft- 6mo,etc. Please list all over-the-counter drugs you take regularly and why. For example: aspirin -for migraines, Unisom -difficulty sleeping etc. 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

Are you allergic to Spironolactone or any of the ingredients in Topical Spironolactone? YES NO

Have you ever been diagnosed in the past with Kidney disease, Hyperkalemia (high potassium) or Addison's disease? YES NO

If yes, please detail and explain diagnosis:

Are you currently taking oral Spironolactone or Aldactone? YES NO

Are you currently pregnant or nursing? YES NO

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


CURRENT MEDICAL CONDITIONS & PAST MEDICAL HISTORY
Do you have or have you ever had any of the following conditions?
Hyperkalemia (high potassium)	Addison's Disease	Liver Disease
Jaundice	Kidney Disease	Eye Pressure Problems
Coronary Artery Disease	Heart Attack	Heart disease
High Blood Pressure	Stroke	Diabetes
Scalp Eczema	Scalp Psoriasis	Scalp Skin Disease
Thyroid disease	Depression
Are you currently taking steroids?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


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	Liver Disease	Stroke
High blood pressure	Heart disease	Arteriosclerosis
Kidney Disease	Gallbladder disease	Cancer
Prostate Cancer	Glaucoma	Addison's disease
Are there any other diseases than run in your family?

**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:Rogaine/minoxidil Propecia (finasteride)Avodart (dutasteride)LatisseNizoral ShampooSurgicalOther
If other, please list
At what age did you first notice hair thinning?
Was your hair loss Sudden or Gradual
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
Are you currently being treated for cancer?YES NO If yes, please explain:
Is your Hair loss due to chemical treatment of your hair - perms? relaxing? coloring? or from hairstyle such as cornrowing? ponytail?YESNO
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 using any other medicines on your scalp?YES NO If yes, please explain:
Please describe your history of hair loss:


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

Please select your current Norwood Classification: Class 2: Receding HairlineClass 3: Generalized Frontal Thinning Class 4: Frontal Area & Crown Balding Class 5: Top of Scalp & Crown Balding Class 6: Extensive Hair LossClass 7: Severe Hair Loss Only rim of hair remains

**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
FULL NAME:
ADDRESS: (Physical Address Necessary We do NOT process any orders to PO BOX#'s)
CITY:
STATE:	ZIP CODE
COUNTRY:
PHONE (REQUIRED):
EMAIL: (REQUIRED)
Please provide complete email, ie You@domain.com or name@aol.com
NAME OF CREDIT CARD HOLDER
ENTER CREDIT CARD TYPE:
ENTER CREDIT CARD NUMBER
EXPIRATION DATE(MM/YY):
Enter you credit card 3 digit security number. To find this number turn your card around and on the back on the strip where you sign your name there are some numbers printed. There are either a set of 4 numbers (the last 4 numbers of your credit card) and a set of 3 numbers, or just a set of 3 numbers. The set of 3 numbers is the security number that is necessary in order to process your request.
ENTER 3 Digit Security Code
BILLING ADDRESS:
BILLING ZIP CODE

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.)YES NO


AVAILABLE IN UNITED STATES ONLY Services not available in Arkansas, Illinois, or Florida Your prescription for your compounded Topical Spironolactone formulation will be forwarded to Trinova Health pharmacy. Trinova Health pharmacy is a compounding pharmacy and they will contact you directly by email and/or phone for your payment and shipping information. (Trinova Health 813-551-1165) You can choose whether you want a 2% or 5% Spironolactone formulation and whether you want it as a solution, lotion or cream: Topical Spironolactone is only available in the following strengths and formulations compounded by Trinova Health pharmacy: 2% Compounded Topical Spironolactone 65ml 2% Spironolactone alcohol SOLUTION 65ml 2% Spironolactone LOTION 60gm 2% Spironolactone CREAM 5% Compounded Topical Spironolactone 65ml 5% Spironolactone alcohol SOLUTION 65ml 5% Spironolactone LOTION 60gm 5% Spironolactone CREAM 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, shipping costs and whether they can ship to your destination if out of the United States, you need to contact Trinova Health pharmacy directly either by email Contact@trinovahealth.com or by phone 813-551-1165. 1. Indicate your choice of Topical Spironolactone strength and formulation: 2 % Compounded Topical Spironolactone 65ml 2% Spironolactone alcohol SOLUTION 65ml 2% Spironolactone LOTION 60gm 2% Spironolactone CREAM 5% Compounded Topical Spironolactone 65ml 5% Spironolactone alcohol SOLUTION 65ml 5% Spironolactone LOTION 60gm 5% Spironolactone CREAM 2. Next after making the above selection, select whether you REGULAR or EXPRESS SERVICE: Regular service - $49.95 consultation fee plus $10.30 processing fee to Medical Wellness Center for the online doctor visit. Consultation reviewed in 3 - 7 business days and forwarded to Trinova Health pharmacy. Express Service - $49.95 consultation fee plus $20 express fee. Consultation reviewed and your prescription forwarded to Trinova Health pharmacy within approximately 24 hours. Please check below whether you want Regular service or Express service REGULAR SERVICE: Consult reviewed and your prescription forwarded to Trinova Health pharmacy in approximately 3-7 business days. Processing fee $10.35 EXPRESS SERVICE: Consult reviewed and prescription forwarded to Trinova Health pharmacy in approximately 24 hours. Express processing fee $20. Please check here if you are requesting our EXPRESS review and processing of your medical evaluation. If you checked yes and you are approved you will be billed a $20 express processing fee.


By submitting this consultation form, I certify:
I am a 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 Topical Spironolactone is not to be used by anyone under the age of 18. I understand that Topical Spironolactone 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 Topical Spironolactone is NOT to be used by pregnant or nursing woman. I am aware that I need to inform my doctor that I am using Topical Spironolactone 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 $49.95 (plus S and P $10.35 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 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 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 make sure that Trinova Health pharmacy can ship the medication to your location or Country. Also, if the pharmacy refuses to fill a valid prescription issued by Medical Wellness Center due to 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. **Medical Wellness Center is not affiliated or associated with Trinova Health pharmacy. Trinova Health pharmacy is a privately owned pharmacy and is completely independent of Medical Wellness Center. Medical Wellness Center provides customized treatments based on over 20 years experience treating male pattern hair loss, and they forward all compounded hair loss prescriptions exclusively to Trinova Health pharmacy 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 for Physician Consultation for Compounded Topical Spironolactone

You may submit Consultation Form over the Internet (secure server) by clicking the SUBMIT button.

For any questions
email at wellnessmd@medicalwellnesscenter.com


PHONE NUMBER: (US ONLY)	617-367-8887
Medical Wellness Center Boston, MA

To contact Medical Wellness Center with any questions, please Email us.

Medical Wellness Center