Dermatology order form hair loss - Pharmacy Solutions

Skip to content

817-274-0050

Pharmacy Location

Products search

Sign In

Edit Content

Click on the Edit Content button to edit/add the content.

Reorder

Favorites

Facebook Twitter Youtube Instagram Linkedin Tiktok

Home
Patients
FOR MEN

Men's Health

Hormone Replacement (BHRT)

Erectile Dysfunction

Hair Loss

Weight Loss

FOR WOMEN

Health & Wellness

Sleep

Weight Loss

Memory Loss / Brain Health

Hormones (BHRT)

Women's Supplements

Children's health

Synapsin & Autism

Back to School Vitamins

Shop Children's Health

CONTACT

Contact Us

Ask A Pharmacist

Refill Your Prescription

Transfer Your Prescription

Sign Up for Our FREE Patient Education Seminar

Sale!

Quick View
Metagenics Ultra Flora Immune Booster 30 Capsules
Digestive and Gut Health
Rated 0 out of 5
$34.00
Add to cart
Providers
Dermatology
Hair Loss
Oncology Hope
Chronic Illness
Vet Corner
Shop
Blog
About
Contact

Pharmacy Solutions - RX Compound

Products search

Home
Patients
FOR MEN

Men's Health

Hormone Replacement (BHRT)

Erectile Dysfunction

Hair Loss

Weight Loss

FOR WOMEN

Health & Wellness

Sleep

Weight Loss

Memory Loss / Brain Health

Hormones (BHRT)

Women's Supplements

Children's health

Synapsin & Autism

Back to School Vitamins

Shop Children's Health

CONTACT

Contact Us

Ask A Pharmacist

Refill Your Prescription

Transfer Your Prescription

Sign Up for Our FREE Patient Education Seminar

Sale!

Quick View
Metagenics Ultra Flora Immune Booster 30 Capsules
Digestive and Gut Health
Rated 0 out of 5
$34.00
Add to cart
Providers
Dermatology
Hair Loss
Oncology Hope
Chronic Illness
Vet Corner
Shop
Blog
About
Contact

Dermatology Order Form Hair Loss

Please enable JavaScript in your browser to complete this form.

Layout

Patient Name *

DOB *

Address

State

Date *

Phone *

City

Zip

Product

Latanoprost / Minoxidil / Finasteride

Layout

Strength

Quantity

Form

Refills

SIG

Product

Latanoprost / Minoxidil

Layout

Strength

Quantity

Form

Refills

SIG

Product

Minoxidil

Layout

Strength

Quantity

Form

Refills

SIG

SIG

Product

Minoxidil/Finasteride

Layout

Strength

Quantity

Form

Refills

SIG

SIG

Product

Minoxidil/Salicylic Acid

Layout

Strength

Quantity

Form

Refills

SIG

SIG

Product

Finasteride

Layout

Strength

Quantity

Form

Form

Refills

SIG

SIG

Product

Fluocinonide/Azelaic Acid/Minoxidil/Tretinoin

Layout

Strength

Quantity

Form

Refills

SIG

Product

Minoxidil/Finasteride/Azelaic Acid/Progesterone/Tretinoin

Layout

Strength

Quantity

Form

Refills

SIG

Product

Minoxidil/Finasteride/Estradiol

Layout

Strength

Quantity

Form

Refills

SIG

SIG

Product

Progesterone

Layout

Strength

Quantity

Form

Refills

SIG

Product

CoQ10/Green Tea Extract/Progesterone/Zinc Oxide

Layout

Strength

Quantity

Form

Refills

SIG

Add Ins (All addins)

Add Ins at $15 each

Layout

Add in ingredient

Saw Palmetto- 2%
Zinc Sulfate- 0.1%
Niacinimide -0.5%
Ketoconazole- 2%
Biotin - 0.03%
Estradiol- 0.025%
Fluocinonide-0.01%
Azelaic Acid- 5%
Caffeine - 1%
Progesterone- 0.25%
Spironolactone-1.247%
Green Tea- 0.1%
CoQ10- 0.2%
Zinc Oxide- 0.1%

Benefits

patients who have high testosterone, male or female. Male pattern baldness
people with dull hair who want to add shine
patients who have high testosterone, male or female. Male pattern baldness
patients with history of fungal infections of scalp
B vitamin used for promoting healthy growth of hair, skin & nails. Good for all patients.
female patients only
patients who have sensitive skin
patients who have high testosterone, male or female. Male pattern baldness
patients who have high testosterone, male or female. Male pattern baldness
female patients only
females with PCOS, patients with high testosterone, male or female. Male pattern baldness
inhibits the activity of hormones that induces hair loss
helps with hair length
patients who have high testosterone, male or female. Male pattern baldness

Study to reference

View
View
View
View
View
View
View
View
View
View
View
View
View

Customize my own formula

charge *

Charge to the provider
Charge to the patient

Layout

Product X

RIZN Complex

Benefit

x

Quantity *

Quantity X *

Layout

Product X

RIZN Spray

Benefit

x

Quantity *

Quantity X *

Layout

Product X

PLENTY Complex

Benefit

x

Quantity *

Quantity X *

Layout

Product X

PLENTY Spray

Benefit

x

Quantity *

Quantity X *

Layout

Product X

Derma Roller

Benefit

Quantity *

Quantity X *

Layout (copy)

Practitioner Name *

Address *

State *

Phone *

Physician Signature

NPI *

City *

Zip *

Fax

Date *

1921 West Pioneer Parkway
Arlington, Texas 76013

800-542-5767
817-274-0050
817-860-6083

Quick Links

Facebook Youtube Tiktok Podcast

Copyright 2023 © All rights Reserved.

Shopping Cart

Sign in
New account

LOGIN TO YOUR ACCOUNT

To purchase Otho Molecular products, please either log in or create an account.

Remember me

Forgot your password?

CREATE AN ACCOUNT

To purchase Otho Molecular products, please either log in or create an account.

I agree with the Terms and Conditions.

Lost your password? Please enter your email address. You will receive mail with link to set new password.

X

Pharmacy Solutions
1921 W Pioneer Pkwy,
Arlington, TX 76013

Click here for driving directions.

Pharmacy Solutions - RX Compound

ATTENTION!

YOUR FORM IS NOT SUBMITTED

To submit your order, click the “PRINT/SAVE” button located under this pop-up.

You can save the PDF to your computer to fax at a later date or print it now to fax immediately.

Printing Copy Save

Fax your order form to 817-860-6083 for processing.

×

Why Choose to Autoship?

Automatically re-order your favorite products on your schedule.
Easily change the products or shipping date for your upcoming Scheduled Orders.
Pause or cancel any time.

Autoship powered by

item added to cart.

Continue shopping View cart & Checkout

x