Hair Restoration Order Form

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ORDER FORMS

Total # of scripts in this order

Enter the total number of prescriptions you are sending with this order so we can confirm we’ve received them all.

Patient Information

Name(Required)

First Last

Email

Enter Email Confirm Email

Phone

Gender(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Allergies(Required)

Billing Options

Billing Clinic(Required)

Bill Clinic | Patient Pickup

Bill Clinic | Mail to Patient

Bill Clinic | Clinic Pickup

Bill Clinic | Mail to Clinic

Bill Patient | Patient Pickup

Bill Patient | Mail to Patient

All formulas are customizable. Please ask if you need a formulation not listed below.

Formulas

Biotin 10mg/ml Injectable Solution

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

Directions

Quantity

Refills

Provider Information

Prescriber Name(Required)

Name of person sending this fax

If you are not the provider, enter your full name so we can verify who submitted this order on their behalf.

Office Phone(Required)

Office Fax

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

NPI/DEA#

Date

MM slash DD slash YYYY

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Signature

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We Balance Nature and Science to provide
Life Changing Benefits

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Patients
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3100 Galleria Drive, Suite 304 Metairie, LA 70001

(504) 267-9876

(504) 267-9877

Monday-Thursday 9am-5pm
Friday: 9am-4pm
Saturdays & Sunday: Closed

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