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	Propecia^® Prescription Consultation

Review and update your account information.

Use the Account Manager to view your current records. If any personal or medical information has changed since your last visit, please update and re-submit your records before continuing. Be sure to check that your general information, medical history, current medications, and allergy charts are all up-to-date.

Complete the following medical review.

The questions below are specific to receiving a Propecia^® prescription. This information will be evaluated in conjunction with your general medical records from "Step 1". Please answer all questions truthfully and completely, to the best of your knowledge.


	Where do you want to purchase this medication?
	Store #

	What dosage and/or treatment duration are you requesting?


	What is your current weight?
	lbs.

	What is your height?


	Have you had a complete physical exam with blood tests within the last year?
	Yes No

	How is your blood pressure?


	Have you taken this medication before?
	Yes No
	If yes, did you have any side effects when you last took this product?


	Do you have any questions or concerns about this product and your health?


	Do you believe you are suffering male pattern baldness?
	Yes No

	How old were you when you started losing your hair?
	Years old

	Was your hair loss sudden or gradual?
	Sudden Gradual

	Does male pattern baldness run in your family?
	Yes No

	What is the primary area of hair loss?
	Frontal Midscalp Crown Sides/Back

	Have you been treated for hair loss before?
	Yes No

	Do you understand the following statements? Propecia can not be taken and can not even be handled by women of child bearing years. Serious birth defects can result, and you agree that you have read and understood this information and limitation.
	Yes No

Verify your order.

You certify that all account information is current, accurate, and complete?

Yes No

You are requesting the prescription medication(s) solely for your own personal therapeutic and medical needs, and will not distribute any of the medication to others?

Yes No

You will promptly contact a local physician for any necessary medical intervention should a complication or concern result related to the use of a requested medication?

Yes No

You realize there are risks as well as benefits to any medication, even non-prescription drugs. You have been informed of the possible effects, risks, and benefits of this medication?

Yes No

You understand the side-effects of these pills?

Yes No

You understand that you can not have a Propecia^� prescription from more than one physician?

Yes No

You understand that you are ordering a prescription consultation and the fee charged for the consultation is non-refundable and does not include the cost of any medication?

Yes No

You understand that Morris Medical Online Services, Inc. does not guarantee that you will receive a prescription for any medication.

Yes No

You certify that I have and will answer all the questions truthfully?

Yes No

I have answered all questions truthfully,
I have read and agree to the Waiver of Liability
I am legally entitled to receive Propecia^�

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