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 Propecia

[Again, they will need their personal payment information, identical to the other sections.]

Please complete the following medical history form in detail.  It will help inform us of any possible contraindications you may have to taking Propecia. 

I will answer all questions fully and accurately as possible  (yes or no)

I have had a thorough physical exam by a licensed physician within the last year  (yes or no)

Sex  (male or female)

Height:

Current Weight:

Date of Birth:

Please answer each question below accurately:

            Does male pattern baldness run in your family?  (yes or no)

            Have you ever been treated for hair loss before?  (yes or no)

            Do you believe you are suffering from male pattern baldness?  (yes or no)

            What was your approximate age when you first noticed you were loosing hair?

Important notation before taking Propecia:  

It should be noted that very serious birth defects can result in women of  child-bearing years who may be pregnant or may be wanting to become pregnant if they are taking or even handling this particular medication.  It is important to note that you have agreed, read, and understand this information, and the limitations of this product.  I understand the above statements  (yes or no)

It is further important to note that the contraindications to taking Propecia are women, children, women of childbearing potential must not handle crushed or broken tablets, pregnancy and nursing mothers.  Furthermore, precautions should be taken in patients who have hepatic or liver dysfunction. 

Adverse reactions and side effects include, but are not necessarily limited to, decreased sexual desire, erectile dysfunction, and ejaculation disorder. 

I understand the possible side effects of taking Propecia  (yes or no)

[And again, a clarification: that I agree that I am permitted by law to receive these products in my place of residence.  I also certify that I am at least 18 years old.  I certify that I am allowed by law to use a credit card.  Actually, this is going to be the same as all the other processing orders, as previously dictated.]