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zip code

sex

What is your date of birth?

PLEASE ENTER A BLOOD PRESSURE FROM THE LAST 6 MONTHS

HAVE YOU EXPERIENCED A HEART ATTACK IN LAST 6 MONTHS?

DO YOU HAVE A HISTORY OF SEVERE CARDIAC(HEART) DISEASE?

HAS YOUR FATHER HAD A HEART ATTACK BEFORE THE AGE OF 55?

HAS YOUR MOTHER HAD A HEART ATTACK BEFORE THE AGE OF 65?

DO YOU HAVE A HISTORY OF SEVERE LIVER DISEASE OR LIVER FAILURE?

DO YOU HAVE A HISTORY OF SEVERE KIDNEY DISEASE OR KIDNEY FAILURE?

DO YOU HAVE A HISTORY OF PEPTIC ULCER DISEASE (PUD)?

DO YOU HAVE A HISTORY OF BLEEDING DISORDERS?

CONGENITAL QT PROLONGATION

This is an abnormal heart rhythm you were born with that would have been diagnosed by a doctor

SPINAL CORD INJURY OR PARALYSIS?

HAVE YOU EXPERIENCED PREVIOUS PROBLEMS WITH ED MEDICATIONS?

Problems such as allergic reactions or unnaceptable side effects

IF SO, WHAT PROBLEMS?

DO YOU HAVE A HISTORY OF PEYRONIE'S DISEASE?

DO YOU HAVE ANY OF THE FOLLOWING? CHECK ALL THAT APPLY?

WHEN APPROXIMATELY DID YOUR ED BEGIN?

HAVE YOU TRIED OTHER METHODS OTHER THAN MEDICATION FOR ED?

Please write which methods

ARE YOU CURRENTLY BEING TREATED FOR OTHER MEDICAL CONDITIONS?

WHAT MEDICATIONS ARE YOU TAKING? PLEASE INCLUDE OVER THE COUNTER MEDICATION AND HERBAL SUPPLEMENTS OR VITAMINS

IS THERE ANYTHING ELSE ABOUT YOUR MEDICAL HISTORY WE SHOULD KNOW?

ARE YOU ALLERGIC TO MEDICATIONS?

TREATMENT OPTIONS

PLEASE SELECT ONE

CHOOSE THE PICTURE THAT BEST REPRESENTS YOUR DEGREE OF HAIR LOSS.

WHEN DID YOU FIRST NOTICE HAIR LOSS?

HAVE YOU TRIED HAIR LOSS TREATMENTS BEFORE?

PLEASE LIST PREVIOUSLY USED TREATMENTS

HAVE YOU BEEN DIAGNOSED WITH OR HAVE THE FOLLOWING CONDITIONS? PLEASE CHECK ALL THAT APPLY

DO YOU HAVE INCOMPLETE HAIR LOSS IN OTHER PARTS OF THE BODY?

PLEASE TYPE WHERE

HAVE YOU RECENTLY STARTED A NEW MEDICAL TREATMENT, SUCH AS CHEMOTHERAPY?

PLEASE WRITE WHICH ONES HERE

HAVE YOU BEEN DIAGNOSED WITH OR HAVE THE FOLLOWING CONDITIONS? PLEASE CHECK ALL THAT APPLY

ARE YOU CURRENTLY TAKING ANY MEDICATIONS PLEASE INCLUDE OVER THE COUNTER MEDICATIONS AND HERBAL OR VITAMIN SUPPLEMENTS

ARE YOU ALLERGIC TO MEDICATIONS?

IS THERE ANYMORE IMPORTANT MEDICAL INFORMATION WE SHOULD KNOW?

TREATMENT

PROPECIA, GENERIC FINASTERIDE

Oral finasteride is an FDA approved medication for hair loss. Finasteride has been studied and shown to have a high efficacy and high tolerability. Most men benefit from the SLOWING of hair loss (so it’s better to start now!) but some men will also see REGROWTH. Finasteride is a 1mg tablet taken once daily with or without food.

Common side effects include erectile dysfunction, decreased libido, and ejaculatory dysfunction. Please contact us or your doctor if you start to experience gynecomastia, testicular pain, or depression. If you start to feel depressed or have suicidal ideations, stop the medication immediately and contact us or your doctor. For more information, side effeects, commonly asked questions, concerns,and pricing please see below. PLEASE READ BELOW IMPORTANT SAFETY INFORMATION INCLUDING RARE BUT SERIOUS SIDE EFFECTS.

ENTER YOUR PREFERRED PHARMACY INFORMATION HERE

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Total Payment Value: $40.00