Medical Wellness Center Online Medical History & Consultation Form for Propecia Rx to treat Male Hair Loss

PROPECIA Consultation: Medical Evaluation Form

Please fill in all fields and respond to all questions honestly and completely so that a physician can review your consultation and prescribe Propecia or Proscar if approved. If the consulting physician determines that Propecia is not appropriate for you, there is NO charge for this consultation. Available in the United States Only

Not available in Illinois and Arkansas and Florida

Choices Propecia or Proscar Brand Name or Generic:
Choose either a 6 month prescription for Propecia(finasteride 1mg) or Proscar(finasteride 5mg). Proscar is only prescribed at the dose of 1/4 pill per day, because higher doses of 5mg/day prescribed for prostate problems has been shown to be associated with a higher incidence of a very aggressive form of prostate cancer.

Select below your choice of either generic finasteride or Brand name or Propecia 1 mg daily or or Proscar 1/4 pill daily:
****Make sure you check first with the pharmacy regarding cost of Brand Name vs Generic - there is a significant difference in price. Once your prescription is called into your pharmacy or you receive your written prescription you can not change it to generic if you later find out it is too expensive. It is YOUR responsibility to check first with the pharmacy. So if you have any questions about medication pricing, check first with your pharmacy regarding the difference between brand name Propecia/Proscar and generic finasteride.

Genuine PROPECIA 1mg finasteride - one pill daily for male hairloss
Generic finasteride 1mg - one pill daily for male hairloss
BRAND NAME PROSCAR 5mg - 1/4 pill daily for male hairloss
Generic finasteride 5mg (generic PROSCAR 5mg) - 1/4 pill daily for male hairloss
Finasteride 0.1% Topical Solution (ONLY AVAILABLE from Trinova Health pharmacy)
Finasteride 0.05% Topical Solution (ONLY AVAILABLE from Trinova Health pharmacy)

Click here to read the stated conditions before filling out the medical consultation form: I have read the previous Propecia 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:

Please list all current Medical Conditions:

Please list all current Prescription Medications:

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

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
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
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?YesNo
Check each treatment that you have undergone:Rogaine/minoxidilSurgicalOther
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:

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 Loss Class 7: Severe Hair Loss Only rim of hair remains

**PERSONAL and PAYMENT INFORMATION**
**Available in the United States Only**
**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:
CITY:
STATE:	ZIP CODE
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

You can choice to fill your prescription at your Local United States pharmacy. Our prescriptions can only be filled at a local United States pharmacy of your choice, they can not be filled at internet or foreign or Canadian or internet versions of pharmacies:

Regular Service: receive a written prescription by mail in 7-15 days and fill your prescription at most any local United States pharmacy of your choice
EXPRESS Service: your prescription is called into the local United States pharmacy of your choice in approximately 24 hours.

Medical Wellness Center does not sell or dispense any medications and we are not affiliated with any pharmacies. For pricing and price comparisons, you need to contact the pharmacy directly.

1. First, choose whether you want regular service (receive written prescription in 7-15 days) or Express 24 hour service.
REGULAR SERVICE: Consult reviewed within approximately 3-7 business days and your will receive a written prescription by mail in approximately 7- 15 days which you can take to most any local United States pharmacy of your choice and fill. Processing fee $10.35
EXPRESS SERVICE:   Consult reviewed and prescription called into most any local United States pharmacy of your choice 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 called into your LOCAL United States pharmacy of your choice within 24 hours. If you checked yes and you are approved you will be billed a $20 express processing fee.   If you are requesting express service, please enter complete phone# including area code, name and address of pharmacy where you choose to fill your prescription.    The prescription can only be called into your local U.S. pharmacy. It can not be called in, faxed or filled at an internet pharmacy, foreign pharmacy, Canadian pharmacy or pharmacies such as Amazon.com or an internet version of a local pharmacy such as CVS.com etc.
If you selected Express service, confirm the name and phone number of your Local United States Pharmacy below:
Name, Phone # Address of EXPRESS Pharmacy.

2. Next, choose whether you want to receive BRAND Name Propecia or Proscar (much higher price at the pharmacy) or Generic finasteride 1mg or finasteride 5mg.
Make sure you check first with your chosen pharmacy regarding pricing of Brand Name Propecia or Proscar vs generic finasteride.   There is often a big price difference. If you select brand and later find out it is too expensive there is a $25 service fee for Medical Wellness Center to change the prescription to generic.
Genuine BRAND NAME Propecia 1mg # 90 with 1 refill
Genuine BRAND NAME Propecia 1mg #30 with 6 refills
Generic finasteride 1 mg #90 with 1 refill
Generic finasteride 1 mg #30 with 6 refills
Genuine BRAND NAME Proscar 5mg #30 with 1 refill (1/4 pill per day)
Genuine BRAND NAME Proscar 5mg #8 with 6 refills (1/4 pill per day)
Generic finasteride 5mg (generic Proscar 5mg) #30 with 1 refill- 1/4 pill daily for male hairloss
Generic finasteride 5mg (generic Proscar 5mg) #8 with 6 refills- 1/4 pill daily for male hairloss
Generic finasteride 0.1% Topical Solution with six refills (Only available from Trinova Health pharmacy 813-551-1165)
Generic finasteride 0.05% Topical Solution with six refills (Only available from Trinova Health pharmacy 813-551-1165)

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 Propecia is not to be taken by women or anyone under the age of 18.
I understand that crushed or broken tablets or capsules MUST not be handled by women who might be pregnant.
I am aware that I need to inform my doctor that I am taking Propecia if I have a PSA blood test.
I do not have any of the contraindications to therapy.
I do not have a current prescription for Propecia from another physician.
I understand that my credit card will be billed $49.95 (plus S&H $10.35) for the medical consultation if approved, if not approved there is no charge for the consultation. 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 & H 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.

Please check here if you are requesting our EXPRESS (available in United States only) review and processing of your medical evaluation. If approved your prescription will be called into a local U.S. pharmacy of your choice within 24 hours. We do not call in prescriptions to Internet pharmacies or foreign pharmacies or Canadian pharmacies. If you checked yes and you are approved you will be billed a $20 express processing fee. If you are requesting express service, remember to please enter complete phone# including area code, name and address of pharmacy where you choose to fill your prescription above.

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 SELECTION made above of receiving written Rx, Express Service called into local U.S. pharmacy: -

Option 1 : Regular Service - receive written prescription by mail in 7-15 days
Option 2 : EXPRESS Service - have prescription called into a local U.S. pharmacy within approximately 24 hours
If you selected Express service, confirm the name and phone number of your Local United States Pharmacy below:
Name, Phone # Address of EXPRESS Pharmacy
Option 3: Tropical finasteride Regular Service: consult reviewed and forwarded to Trinova Health copounding pharmacy (813-551-1165) in 3 - 7 days
Option 4: Topical finasteride- Express Service: consult reviewed and forwarded to Trinova Health compounding pharmacy (813-551-1165) in approximately 24 hours

Make sure that you have selected whether you want PROPECIA or PROSCAR!!

Click SUBMIT button for Physician Consultation for Propecia/ Proscar

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@medicalwellnesscenter.com

To 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