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info@galleriamedpharmacy.com
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Hair Restoration Order Form
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Enter the total number of prescriptions you are sending with this order so we can confirm we’ve received them all.
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All formulas are customizable. Please ask if you need a formulation not listed below.
Formulas
Metformin 5% Cream
Metformin 10% Cream
Estradiol 0.1% Cream
Estradiol 0.06%/Melatonin 0.05%/Spirolactone 0.1%/ Finastride 0.5%/ Minoxidil 2% Spray
Testosterone 0.5%/Spirolactone 0.1%/ Finastride 0.5%/Minoxidil 5% Spray
Minoxidil 5%/Azelaic Acid 12.5% Spray
Minoxidil 5%/Azelaic Acid 12.5%/Finasteride 0.1% Spray
Minoxidil 5%/Finasteride 0.1% Spray
Minoxidil 5%/Finasteride 0.1%/Tretinoin 0.025% Spray
Minoxidil 5%/Azelaic Acid 12.5%/Finasteride 0.1%/Ketoconazole 2% Spray
Minoxidil 5%/Hydrocortisone 1% Spray
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Refills
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Provider Information
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