Customized COMPOUNDED MINOXIDIL:  Medical REFILL Evaluation Form 
Minoxidil PrescriptionWelcome back? After your initial consultation and MINOXIDIL approval each follow-up consultation, if approved, is only $75 and 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 3 months of treatment you may start to notice some improvement and for some improvements are not noticed until 6 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. Please accurately and completely provide the following information in order for a physician to review your record. 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.)
Minoxidil is available ONLY in these formulations:
5% Foam with NO additives
5% Spray Liquid with 5% Azelaic Acid & 0.1% finasteride Only additive choices 
5% Lotion
12.5% Lotion 
15% Lotion or Cream
30% Cream Only 
Additive Choices: Tretinoin, Azelaic Acid, Progesterone, Finasteride, Hydrocortisone (IF YOU HAVE GLAUCOMA OR ARE SENSITIVE TO STEROIDS DO NOT SELECT 1% Hydrocortisone)
Vitamin E and DMI enhancer are standard in all lotions and creams and prepared in propylene glycol base
NOT AVAILABLE IN ILLINOIS AND ARKANSAS AND FLORIDA
If you are requesting Murray Avenue Apothecary to ship out of the United States, you need to contact the pharmacy first to make sure they ship to you location.  There are NO refunds for consultations if the pharmacy can not ship to your location.
Click here  to read the stated conditions before filling out the medical consultation form: 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 

Please fill in all fields and respond to all questions honestly and completely so that a physician can review your consultation and prescribe Minoxidil if approved.   If the consulting physician determines that Minoxidil Refills are not appropriate for you, there is NO charge for this consultation. 
The medical information you supply is subject to ALL patient/doctor privilege laws.
MEDICAL HISTORY
First and Last Name:
Medical Wellness Center Membership Number for returning clients for customized Minoxidil formulations: 
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.

Do you have a prescription from Medical Wellness Center for Propecia or Avodart?YESNO

SEX: Female  Male 
Date of Birth(MM/DD/YY):         Current Age: 
Height (inches):Weight:

Are you a former patient of Dr. Klein?YESNO
If YES, please list the formulations you were using.

If YES, please describe your treatment regimen.... how often you used the product and when you applied the product - mornings or evenings etc.

Did you experience any  side effects:YES NO
If yes, have these symptoms resolved? YES NO
If yes, please describe symptoms:

Describe your response to customized MINOXIDIL  treatment and detail the progress. Detail 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?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? YESNO
(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?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, Avodart; Propecia, etc.

Do you currently take oral  Propecia, Proscar or finasteride?YESNO

Do you currently take oral Avodart or dutasteride?YESNO

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 
 
Do you suffer from Male Pattern Hair loss?YESNO
Do you have or are you being treated for glaucoma - increased intraoccular eye pressureYES  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?YESNO
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 
CURRENT MEDICAL CONDITIONS & PAST MEDICAL HISTORY
Do you have or have you ever had any of the following conditions?
Glaucoma gallbladder disease Liver Disease
Scalp Eczema Cirrhosis of Liver Hepatitis
Scalp Psoriasis Kidney Disease Prostate problems
Scalp Skin Disease Enlarged Prostate Elevated PSA Levels
Coronary Artery Disease Heart Attack Heart disease
High Blood Pressure Stroke Diabetes
Thyroid disease Depression Endocrine Disorders
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
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 Benign Prostate Enlargement Male Baldness
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 PropeciaAvodartSurgicalOther 
If other, please list
At what age did you first notice hair thinning?
Was your hair lossSudden not due to Male Pattern Hair loss  or 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?YESNO
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: 
Norwood Classification of Male Pattern Baldness - Propecia
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 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
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
EXPIRATION DATE(MM/YY):
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
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 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) 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. 

   **** If you are requesting Murray Avenue Apothecary to ship out of the United States, you need to contact the pharmacy first to make sure they ship to you location. 
There are NO refunds for consultations if the pharmacy can not ship to your location.

Your prescription for your compounded topical Minoxidil preparation will be forwarded to Murray Avenue Apothecary. Murray Avenue Apothecary is a compounding pharmacy and they will contact you directly by email for your payment and shipping information.  www.maapgh.com
You can choose:

  • The strength of minoxidil
  • Additives to enhance hair growth and the effectiveness of the formulation (IF YOU HAVE GLAUCOMA OR ARE SENSITIVE TO STEROIDS DO NOT SELECT HYDROCORTISONE ADDITIVE )
Minoxidil is available ONLY in these formulations:
5% Foam with NO additives
5% Spray Liquid with 5% Azelaic Acid & 0.1% finasteride Only additive choices 
5% Lotion
12.5% Lotion 
15% Lotion or Cream
30% Cream Only 
Additive Choices: Tretinoin, Azelaic Acid, Retinoic Acid, Progesterone, Finasteride, Hydrocortisone (IF YOU HAVE GLAUCOMA OR ARE SENSITIVE TO STEROIDS DO NOT SELECT 1% Hydrocortisone)
Vitamin E and DMI enhancer are standard in all lotions and creams and prepared in propylene glycol base
**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 Murray Avenue Apothecary. For pricing you need to contact Murray Avenue Apothecary either at susan@maapgh.com   or tonya@maapgh.com. 


1. Indicate your choice of  Minoxidil strength:

5% Minoxidil Lotion 
12.5 % Minoxidil Lotion 
15% Minoxidil  Lotion or 15% Minoxidil Cream
30% Minoxidil Cream 
2. Indicate your choices of optional additives to the above selected Minoxidil Strength. 
 
No additional Additives
5% Azelaic Acid
0.025% Tretinoin (Retinoic Acid)
0.25% Progesterone 
0.1% Finasteride (Do not add topical finasteride if taking Avodart -dutasteride or Propecia/Proscar - oral finasteride or using topical Dutasteride)
0.1% Hydrocortisone -(Do NOT select if you have glaucoma or allergic/sensitive to steroids)


 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:


In addition for one consultation fee you can also choose to receive a prescription for:
  • 5% Minoxidil Spray with your choice of additives
  • 5% Minoxidil Foam and/or an additional prescription for 
  • Acetyl Glutathione hair maturation enhancer with 3% Biotin  
    • 1.  Choose an additional prescription for 5% Minoxidil Spray  with 5% Azelaic Acid and/or 5% Minoxidil Foam
    5% MINOXIDIL SPRAY with 5% Azelaic Acid
    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, 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.
    0.1% Finasteride additive to the 5% Minoxidil spray
    5% MINOXIDIL FOAM (no additives)

    5% MINOXIDIL SHAMPOO(no additives)

    2.  Choose an additional prescription for Acetyl Glutathione with 3% Biotin in Propylene solution, a topical enhancer which comes in a dropper bottle at 30ml size.
    Acetyl Glutathione  biotin 3% Propylene solution - 30ml dropper bottle: Acetyl Glutathione is the body's only naturally manufactured antioxidant.  Acetyl Glutathione 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 Propylene glycol base - the Biotin promotes growth of immature hairs and the Acetyl Glutathione promotes the maturation of the hair follicle.

    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 faxed to Murray Avenue Apothecary.

    Express Service - $75.00 consultation fee plus $20 express fee.  Consultation reviewed and your prescription faxed to Murray Avenue Apothecary 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   - consult reviewed and faxed to Murray Avenue Apothecary within 3 - 7 days 
    Express service   - consult reviewed and faxed to Murray Avenue Apothecary within approximately 24 hours 

    Confirm you selection of Topical Hair Loss formulations selected above:
    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  (if you check your spray bottle, you will notice that the additives settle to the bottom and the spray is mostly alcohol)
    5% Minoxidil Foam with no additives
    Acetyl Glutathione  with 3% biotin in propylene glycol, an enhancer which is a topical formulation used in addition to Minoxidil lotion or cream products which promotes the new immature hair follicles  to MATURE.
    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.

    How did you learn about our Minoxidil Website and or Murray Avenue Apothecary?
    Former Dr. Klein Patient 
    Referred by Jazz
    Referred from a Chat Room or Blog

    Please list Chat Room or Blog you learned about Medical Wellness Center or Murray Avenue Apothecary compounded hair loss formulations
    Other
    If learned about us from another source other than listed above such as a search engine such as google, please tell us your source
    **Medical Wellness Center is not affiliated or associated with Murray Avenue Apothecary.  Murray Avenue Apothecary 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 Murray Avenue Apothecary because of the integrity and reliability of this United States based, privately owned, local pharmacy; the experience of Susan Merenstein, the compounding pharmacist; and that this pharmacy only uses FDA approved ingredients.


    Click SUBMIT button for Physician Consultation for topical Minoxidil cream or lotion
    You may submit Consultation Form over the Internet (secure server) by clicking the SUBMIT button.
     

    For any questions & fastest reply contact us by
    email at Wellnessmd@yahoo.com
    Email to contact Medicall Wellness Center: Hair-loss treatment for MenTo contact Medical Wellness Center - Hair-loss treatment for Men with any questions, please Email us.

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