1. Eligibility & Safety

• I am not pregnant or breastfeeding, and I will inform my provider if I plan pregnancy.
• I am not allergic to Minoxidil, Biotin, Caffeine, or Melatonin, and I have no known allergy to common topical components (e.g., propylene glycol, alcohols). If I have any allergies, I will list them during intake.

2. Use & Precautions

• I will apply only to the scalp as directed, avoid eyes/face, wash hands after use, and allow the scalp to fully dry before bed.
• I will stop use and seek medical care if I experience severe irritation, swelling, dizziness, chest pain, rapid heartbeat, or unwanted facial hair growth.
• I will not apply on sunburned skin, open wounds, broken/irritated skin, or immediately before/after microneedling/procedures without provider guidance.
• I understand initial increased shedding may occur in the first weeks and that visible benefits may take about 3 months of consistent use.

3. Medical History & Screening

• I will disclose any drug or topical product allergies (e.g., preservatives, fragrance, lanolin).
• I will list any current hair/scalp treatments I use (e.g., topical/oral minoxidil, finasteride/dutasteride, spironolactone, ketoconazole shampoo, steroids, retinoids, PRP/microneedling).
• I will list all medications and supplements I take.
• I will disclose any current or past medical conditions, including heart disease, chest pain, arrhythmia, low blood pressure, edema/swelling, kidney or severe liver disease, thyroid or iron issues, PCOS, or any major recent illness/surgery.
• I will describe my treatment goal, symptoms & duration, and scalp areas affected during the intake.

4. How the Medication is Provided

• I understand this therapy may be dispensed as a compounded topical using USP-grade ingredients by a licensed pharmacy.
• My instructions (amount, frequency, and duration) will be individualized by the provider based on my condition and goals.

5. Side Effects & When to Seek Care

• I have reviewed treatment information and understand potential side effects such as scalp irritation/itching, dryness, dermatitis, unwanted facial hair growth, dizziness, fast heartbeat, swelling, and headache.
• I agree to seek medical attention if severe side effects occur and to inform my provider about any new medications, pregnancy plans, or scalp procedures.

6. Identification & Confidentiality

• Uploading a valid government-issued photo ID is a legal requirement to verify my identity before the consultation can be completed.
• This verification complies with state and federal telemedicine regulations.
• My personal information and ID will be handled securely, stored confidentially, and never shared except as required by law or to provide my medical care.

IMPORTANT: Please keep a clear image of your Driver’s License / State ID / Passport (or photo of any government-issued ID) ready on this device to upload.

7. Consent

• I give my full consent for RightMD INC and its affiliated medical/pharmacy teams to prescribe and dispense this compounded hair-loss solution based on the information I provide.

8. Payments & Refund Policy

• All purchases and services are final and non-refundable.

9. Policies

• I have read and agree to the Terms & Conditions, Privacy Policy, and Refund & Cancellation Policy.