User Manual Prescription – Northwestern Hair

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Date
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Patient's Email
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Prescriber Email
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Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Dutasteride | Biotin (Capsule)
$300.00
Finasteride | Salicylic Acid
$200.00
Minoxidil | Biotin (Capsule)
$300.00
Minoxidil | Dutasteride | Biotin (Capsule)
$300.00
Minoxidil | Dutasteride | Salicylic Acid
$200.00
Minoxidil | Dutasteride | Tretinoin
$200.00
Minoxidil | Finasteride | Salicylic Acid
$200.00
Minoxidil | Finasteride | Tretinoin
$200.00
Minoxidil | Salicylic Acid
$200.00
Minoxidil | Sprinolactone | Biotin (Capsule)
$300.00
Minoxidil | Tretinoin
$200.00
Prescription Product Name*
Dose*
Dose*
Dose*
Dose*
Dose*
Dose*
Dose*
Dose*
Dose*
Dose*
Dose*
Base*
Base*
Size*
Size*
Refills Listed On Prescription*
Refills On Database*
Quantity*
Pharmacy Email*
Instructions*
Pharmacists notes*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Patient Allergies
Phone
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