1. Eligibility & Safety

• I am not allergic to Minoxidil, Finasteride, or Tretinoin, and I have no known allergy to common topical components (e.g., propylene glycol, alcohols, parabens, fragrance). If I have any allergies, I will list them during intake.
• I confirm I do not have heart disease, chest pain, arrhythmia, uncontrolled blood pressure, swelling/edema, or severe liver/kidney disease, and I will disclose other significant conditions.

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 not apply on sunburned skin, open wounds, broken/irritated skin, or immediately before/after microneedling/procedures without provider guidance.
• I will stop use and seek care if severe scalp irritation, swelling, dizziness, chest pain, rapid heartbeat, fainting, breast tenderness, or mood changes occur.
• I understand benefits may take ~3 months of consistent use and that early shedding may occur in the first weeks.

3. Medical History & Screening

• I will disclose any drug/topical product allergies.
• 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 indicate my treatment goal, describe my symptoms & duration, and note the scalp areas affected during intake.
• I will disclose any history of prostate conditions (e.g., BPH, elevated PSA, prostate cancer) or unexplained urinary symptoms; if present I will provide details and dates.

4. Finasteride-Specific Notes

• I understand topical Finasteride is off-label; it may lower PSA values and can cause side effects (e.g., decreased libido, erectile/ejaculatory changes, mood changes).
• I will inform my provider about any PSA testing and promptly report new sexual, breast, testicular, or mood symptoms.
• I will avoid exposing pregnant partners to the medication (do not allow contact with treated skin; wash hands after application; allow full dry time before skin-to-skin or bed contact).

5. Tretinoin-Specific Notes

• I understand Tretinoin may increase skin sensitivity/irritation and can enhance Minoxidil absorption; I will use only as directed and avoid use on broken/irritated skin.

6. How the Medication is Provided

• I understand this therapy may be compounded 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.

7. 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/body hair at contact sites, dizziness, fast heartbeat, swelling, sexual or mood changes, breast tenderness, and headache.
• I agree to seek medical attention if severe side effects occur and to keep my provider informed about new medications or procedures affecting the scalp.

8. 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.

9. 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.

10. Payments & Refund Policy

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

11. Policies

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