Hair Again Clinic

Prescription Oral Hair Loss Medication — Medical Screening Form

For clients requesting oral Minoxidil, Finasteride or Dutasteride.

Confidential Medical Information

Important — Please Read Before Completing This Form

This form collects the information required for an initial safety review. It is not a medical consultation, and completing it does not guarantee that a prescription will be issued.

Hair Again Clinic will review your form and photographs to ensure the required information has been provided. If appropriate, your information will be securely forwarded to our prescribing doctor.

We want you to understand the likely costs before proceeding with a medical consultation.

Doctor consultation: $150 (includes initial consultation & 3 month follow up consultation)

Compounded oral medication: between $145 to $260 for 90 capsules (3 month supply) to be confirmed once actual dose is confirmed.

The prescribing doctor will conduct a video conference consultation with you, review your medical history, discuss the proposed medication and determine whether prescribing is medically appropriate.

How the Process Works

Complete every required question in this form.
Upload the requested hair and scalp photographs.
Hair Again Clinic will check that your information and photographs are complete.
If appropriate, your information will be sent securely to our prescribing doctor.
A teleconference consultation will be arranged with the prescribing doctor.
The doctor will review your medical history, current medications, hair-loss concerns and photographs.
The doctor will discuss the potential benefits, risks, side effects, alternatives and monitoring requirements.
The doctor will decide whether a prescription is medically appropriate.
If medication is prescribed, the dispensing and delivery arrangements will be confirmed.

The $150 fee paid directly to Dr Melissa covers the doctor's consultation and medical assessment and includes a 3 month follow up.

Name(s) on account: Melissa Amertil T/A Melvis Health

Account number: 12-3023-0157565-01

Bank: ASB

It does not guarantee that a prescription will be issued.

Medication, dispensing and courier charges are separate unless Hair Again Clinic advises you otherwise in writing.

Clinic Eligibility Policy for Finasteride and Dutasteride

Hair Again Clinic does not offer Finasteride or Dutasteride to women in either oral or topical form. Finasteride and Dutasteride will only be considered for adult male clients, subject to a full assessment and approval from the prescribing doctor.

Oral minoxidil is not suitable during pregnancy or breastfeeding and still requires complete medical screening and approval from the prescribing doctor

Before You Begin — Please Confirm All of the Following

Pre-screening confirmations

I am 18 years of age or older.

I am currently in New Zealand.

I will be in New Zealand at the time of the doctor's teleconference consultation.

I understand that this form is not suitable for urgent medical concerns.

I understand that urgent or severe symptoms must be assessed by my GP, an urgent-care clinic or emergency services.

I understand that the doctor's consultation fee is $150.

I understand that paying the consultation fee does not guarantee that medication will be prescribed.