FollicaRx

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Date of Birth *

Date

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⚖️ Disclaimer & Consent: FollicaRx™ is a compounded topical serum formulated with active pharmaceutical ingredients including Minoxidil 2%, Latanoprost 0.01%, Niacinamide 2%, Ketoconazole 2%, and Vitamin E 0.5%. It is intended for external use only and should be applied as directed by your healthcare provider. By purchasing this product, you acknowledge and consent that: You are receiving a compounded formulation prepared under the direction of a licensed physician.You have no known allergies or contraindications to any of the listed ingredients. You understand that individual results may vary and that regrowth or improvement cannot be guaranteed. You agree to discontinue use if irritation, redness, or unwanted side effects occur, and to consult a medical professional if needed. This product is not FDA-approved, but it is compounded in compliance with applicable pharmacy and medical standards for patient use. Use is at your own discretion, and by purchasing you consent to treatment under the supervision of the Dr David Wellness medical team.*

Sex assigned at birth:*

State of Residence (please note, if you are not in one of these states, we cannot ship to you):*

How long have you been experiencing hair thinning or loss?*

< 6 months / 6–12 months1–3 years3–10 years> 10 years

Have you previously tried any of the following? Please write which one. If none please write "none." Minoxidil (oral or topical) - Finasteride / Propecia Dutasteride - PRP / micro-needling - Hair transplant - Over-the-counter shampoos - Other prescription treatment.*

Have you had any side effects with prior hair growth solutions?*

YesNo

Are you currently pregnant, trying to become pregnant, or breastfeeding? FollicaRx contains minoxidil and latanoprost, which are not recommended during pregnancy or breastfeeding. We cannot process your order at this time if Yes.*

NoYes

Do you have any history of heart disease, low blood pressure, fainting, irregular heartbeat, chest pain, or pheochromocytoma?*

NoYes

Do you currently have any open wounds, sores, infection, severe sunburn, recent scalp surgery, or active dermatitis on your scalp?*

NoYes

Do you have a history of glaucoma, elevated intraocular pressure, ocular herpes, or any active eye infection?*

NoYes

You understad that Latanoprost is one of the active ingredients and can rarely cause iris pigmentation changes if it reaches the eye, i.e. darkening of the eye color. *

Do you have any history of liver disease, hepatitis, or abnormal liver function tests?*

NoYes

Do you have lupus, alopecia areata, severe psoriasis, severe eczema, or any other autoimmune skin condition?*

NoYes

Have you been diagnosed with any cancer in the past 5 years?*

NoYes

List any chronic conditions you currently have (diabetes, thyroid disease, kidney disease, etc.). If none, write 'None'.*

List ALL current prescription medications (dosages and frequency not needed at this time). If none, write 'None'.*

Are you allergic to or have you had a reaction to any of the following?Minoxidil, Latanoprost or other prostaglandin analogs, Ketoconazole or other azole antifungals, Propylene glycol, Niacinamide / niacinVitamin E / tocopherol*

NoYes

Compounded-medication acknowledgmentI understand that FollicaRx™ is a compounded prescription topical prepared by a licensed compounding pharmacy (Novel Pharmacy, Sylmar, CA). Compounded preparations are not FDA-approved as finished products. The individual active ingredients are FDA-approved for related uses.Telehealth informed consentI consent to receive medical evaluation and prescription services from David Mahjoubi, MD, by telehealth. I understand telehealth has limitations compared to in-person care, that no physical examination will be performed, and that my evaluation is based on the information I have provided in this form. I understand I may withdraw this consent at any time.Side-effect awareness — minoxidilI understand that topical minoxidil may cause scalp irritation, unwanted facial hair growth, dizziness, lightheadedness, rapid heartbeat, swelling, or chest pain. I will discontinue use and contact a physician immediately if any serious side effect occurs.Side-effect awareness — latanoprostI understand that latanoprost may cause skin darkening at the application site, darkening of nearby eyelashes or skin, and — rarely, if it contacts the eye — changes in iris pigmentation. I will avoid eye contact and wash my hands after application.Side-effect awareness — ketoconazoleI understand that topical ketoconazole may cause itching, dryness, irritation, or rare allergic reaction. I will discontinue use if a rash or significant irritation develops.Discontinuation acknowledgmentI agree to discontinue FollicaRx™ and contact Dr. Mahjoubi or seek emergency care if I experience any severe or unexpected reaction (chest pain, palpitations, swelling, severe rash, vision changes, or any other concerning symptom).No substitute for routine medical careI understand FollicaRx™ is intended only for cosmetic management of hair thinning. It is not a substitute for routine primary-care medical follow-up. I will continue to see my primary care physician for general medical care.Doctor-patient relationship scopeI understand that the doctor-patient relationship established through this form is limited to the prescribing of FollicaRx™ and related follow-ups, and does not establish Dr. Mahjoubi as my primary care physician.Truthful disclosureI certify that all information provided in this form is true, complete, and accurate to the best of my knowledge. I understand that providing false or incomplete information may result in serious medical harm and waives any claim against Dr. Mahjoubi or NutraBrain Clinic, Inc. arising from undisclosed conditions.Authorization to dispenseI authorize Dr. David Mahjoubi to send my electronic prescription to Novel Pharmacy (Sylmar, CA) and to share the medical information necessary for them to compound and dispense FollicaRx™ to my shipping address.HIPAA Notice of Privacy PracticesI acknowledge I have been provided access to NutraBrain Clinic, Inc.'s HIPAA Notice of Privacy Practices and consent to electronic communications regarding my care.Communications consentI consent to receive emails and text messages from Dr. David Wellness / NutraBrain Clinic, Inc. regarding my order, follow-up questions, refill reminders, and educational content. Standard message and data rates may apply. I may opt out at any time by replying STOP.Photographs consentI consent to the use of my submitted photographs for medical-record documentation. I understand they will be stored in a HIPAA-compliant medical record system and will not be used for marketing without my separate written consent.Refund / return acknowledgmentI understand that, due to the nature of compounded medications, all sales are final once the seal is broken. Damaged or incorrect shipments must be reported within 48 hours of delivery.*

My Products

FollicaRx

$200.00 Quantity

Total

$0.00

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