TOPICAL DUTASTERIDE REFILL   Medical Evaluation Form 
Online Topical Dutasteride Prescription CompoundedWelcome back. After your initial consultation and Topical Dutasteride approval each follow-up consultation, if approved, is only $75 and includes Topical Dutasteride refill prescriptions good for 12  months.  Hair growth is very slow and it may take up to a year to notice the full benefits.    After the first 3 months of treatment you may start to notice some improvement.  For others, 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 Topical Dutasteride  to stop the natural progression of Male pattern baldness and to prevent the new hair regrowth from thinning out. Do NOT combine Topical Dutasteride with oral  Avodart (dutasteride) and Propecia (finasteride). Do NOT combine Topical Dutasteride with topical finasteride.  Topical Dutasteride can be used simultaneously with topical minoxidil, lastisse, latanoprost, Nizoral shampoo, topical Spironolactone.  One must wait until each topical is completely dry before using another product.  If you are currently taking Propecia or using topical finasteride, discontinue use and begin therapy with Topical Dutasteride. 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.)
 
 
Topical Dutasteride is available in two formulations only:
 
Topical Dutasteride 0.05% Solution 
Topical Dutasteride 0.05% Solution plus 5% minoxidil  
 NOT  AVAILABLE IN ILLINOIS AND ARKANSAS AND FLORIDA

Please fill in all fields and respond to all questions honestly and completely so that a physician can review your consultation and prescribe Topical Dutasteride if approved.   Do NOT combine Topical Dutasteride and oral Propecia (finasteride) or with topical finasteride.  Do not combine Topical Dutasteride and oral  Avodart (dutasteride).  If the consulting physician determines that Topical Dutasteride Refills are not appropriate for you, there is NO charge for this consultation.
Click here  to read the stated conditions before filling out the medical consultation form: I have read the previous Topical Dutasteride  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:

Medical Wellness Center Membership Number: 

SEX: Female  Male 
Date of Birth(MM/DD/YY):         Current Age: 
Height (inches):Weight:
  : 
Did you experience any sexual dysfunction or side effects:YES NO
If yes, have these symptoms resolved? YES NO
If yes, please describe symptoms:
Describe your response to Topical Dutasteride  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.
Have there been any changes in your current medical conditions that the consulting Physician should be aware of?
(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,etc.

Do you currently use topical Minoxidil?YESNO
If Yes, what is the strength and additives in the formulation:

Do you currently take Oral Avodart or Dutasteride?YESNO

Do you currently take Oral Propecia or Proscar (finasteride) or use topical finasteride?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 presently have liver disease, liver function abnormalities, hepatitis or any medical disorder of liver function including but not limited to cirrhosis of the liver, liver cancer, jaundice etcYES  NO 
Are allergic to Avodart, dutasteride, finasteride , Propecia or any of the ingredients in Avodart? YES NO
Are you currently taking  ORAL Nizoral (ketoconazole) or  Sporanox (itraconazole)?YES NO
Are you currently taking Propecia or PROSCAR (finasteride) or using topical Finasteride? YESNO
Are you currently taking oral Avodart (dutasteride)? YESNO
Do you have AIDS or a positive HIV test or have you recently been exposed to AIDS? YES NO
Are you currently taking Protease Inhibitors: Agenerase (amprenavir), Crixivan (indinavir), Viracept (nelfinavir), Norvir (ritonavir) or Invirase or Fortovase (saquinavir)?YES NO
Have you been diagnosed with prostate cancer? YES NO
Do you have BPH - benign prostatic hypertrophy ? 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?
Chronic Malabsorption Syndrome gallbladder disease Liver Disease
Liver function abnormalities Cirrhosis of Liver Hepatitis
Jaundice Kidney Disease Prostate problems
Prostate cancer 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 taking steroids?YES NO
Are you currently being treated for cancer? 
YES NO 
If yes, please explain: 
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 PropeciaSurgicalOther 
If other, please list
At what age did you first notice hair thinning?
Was your hair loss Sudden    or Gradual
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 - Avodart
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

Services not available in Arkansas, Illinois, or Florida 





1.  First choose the Topical Dutasteride formulation 

Topical  Dutasteride 0.05% solution 65ml 
Trinova Health (813-551-1165) is a specialized compounding pharmacy. This pharmacy has excellent pricing, especially for medications that are not covered by insurance. Please check FIRST with the pharmacy in regards to pricing of the medication. 
Topical  Dutasteride 0.05%  plus  5% minoxidil solution 65ml 

If you have any questions in regards to shipping status and tracking information you need to contact the pharmacy directly:   Trinova Health 813-551-1165

2. Next after making this selection then choose whether you want regular service (consult processed in 3 -7 days) or Express 24 hour service.
REGULAR SERVICE:  Consult reviewed and your prescription forwarded to Trinova Health within approximately 3-7 business days. Processing fee $9.50
EXPRESS SERVICE:   Consult reviewed and your prescription forwarded to Trinova Health  within approximately 24 hours.  Express processing fee $20
Please check here if you are  requesting  our EXPRESS  review  and processing of your medical evaluation.  If approved  your prescription will be forwarded to Trinova Health within 24 hours.  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  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 Topical Dutasteride  is not to be taken by women or anyone under the age of 18.
I understand that crushed or broken capsules MUST not be handled by women who might be pregnant and women who might be pregnant should not have direct or indirect contact with dutasteride solution.
I am aware that I need to inform my doctor that I am using Topical Dutasteride  if I have a PSA blood test. Oral  Dutasteride decreases PSA levels by 50% and adjustments are necessary when testing for or monitoring PSA levels for Prostate cancer.  Topical Dutasteride may also affect PSA levels, but not to the same extend as oral systemic therapy.
I do not have any of the contraindications to therapy.
I do not have a current prescription for Avodart from another physician. If currently taking Propecia, I am aware that I must first discontinue Propecia therapy before initiating therapy with Topical Dutasteride
I understand that I must NOT combine Topical Dutasteride with oral Avodart or with oral or topical Propecia or Proscar (finasteride)
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 that I am not purchasing medication  but rather the online consultation service and a prescription for one year to Topical Dutasteride to be compounded and purchased from Murray Avenue Apothecary.  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 for any reason 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. 

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.
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.
 

Please CONFIRM your Topical Dutasteride formulation selection: 
 

Topical Dutasteride 0.05% solution  65ml
Topical Dutasteride 0.05%  + 5% minoxidil solution  65ml


Please CONFIRM YOUR SELECTION made above:

Option 1 : Regular Service - Consult processed and forwarded to Trinova Health in approximately 3 -7 business days 
Option 2 : EXPRESS Service -Consult processed and forwarded to Trinova Health in approximately 24 hours


Click SUBMIT button for Physician Consultation for Topical Dutasteride REFILLS
You may submit Consultation Form over the Internet (secure server) by clicking the SUBMIT button. 

For any questions
email at wellnessmd@medicalwellnesscenter.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