TOPICAL DUTASTERIDE REFILL
Medical Evaluation Form
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Welcome
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 ($89 price to be paid
directly to Murray Avenue Apothecary)
Topical
Dutasteride 0.05% Solution plus 5% minoxidil ($99
price to be paid directly to Murray Avenue Apothecary)
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.
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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:
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Are you currently taking steroids?YES NO |
Are you currently being treated
for cancer?
YES NO
If yes, please explain:
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Have you had surgery in the last
3 months?
YES: NO
If yes, please explain:
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To
contact Medical Wellness Center - Hair-loss treatment for Men with any
questions, please Email us.
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PHONE NUMBER:
(US ONLY) |
617-367-8887 |
Medical Wellness Center
Boston, MA
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