PH: (855) 246-6338 Free Delivery to All Please Fax to: 50 States! (877) 791-7779 www.biomedrelief.com Easy as 1, 2, 3! 1. Review & Complete Rx 2. Sign Rx How to apply H5 Formula 3. Fax Rx to (877) 791-7779 1. Apply 20-30 drops (depending on area of *We will ship to patient’s home coverage necessary) into scalp area of hair Hair Loss Treatment Prescription Order Form loss 2-3 hours before bedtime. Maximum Experience Thicker Patient Information: of 40 drops per day. Do not rinse off scalp PATIENT NAME: DOB: & Fuller Hair! for the next 6 hours; allow for medication
CELLPHONE #: ALLERGIES: (If no allergies please check the NKDA box) NKDA to absorb. It is normal for scalp and hair to
ADDRESS: become sticky. 2. Stay standing and do not lay down for 30 Defy hair loss by regrowing more Rx Medication Order: Pharmacist Please Compound: minutes. Avoid contact with eyes. hair with the #1 dermatology
Rx # H5. Formula 3. Wash hands after use. recommended compounded Minoxidil 10% (active ingredient in Rogaine) Azelaic acid 2% Best to apply at night 2-3 hours before Ketoconazole 2% 4. medication for thinning hair. Tea Tree oil 0.25% Finasteride 0.25% (active ingredient in Propecia) bedtime, then shower in the morning at
QTY: 100ml/$89 200ml/$149 least 6 hours from applying the medication. SIG: Apply 20-30 drops to scalp area of hair loss daily
Refills:______
Prescriber Information: PRESCRIBER’S SIGNATURE: Online Order Forms
1. Visit www.biomedrelief.com NPI#: DATE: 2. Click the “Prescribe Now” button 3. Click on “Hair Loss” button
ADDRESS, CITY, STATE, ZIP: 4. Print the H5 Rx form Before After 5. Bring H5 Rx form to your doctor to discuss your options PHONE #: FAX #: Or have your doctor call 855. 246. 6338 to order by phone
This form is proprietary of BioMed Pharmacy and is only intended for use between provider and patient. Any unautho- rized use could result in legal action. This facsimile transmission is intended to be delivered to the named addressee and may contain information that is confidential, privileged, and proprietary or exempt from disclosure under applicable law. If it is received by anyone other than the names addressee, the recipient should immediately notify the sender at the address and/or telephone PH: (855) 246-6338 FX: (877) 791-7779 number set forth herein and obtains instructions as to the disposal of the transmitted material. In no event should such material be read or retained by anyone other than the addressee, except by express authority of the sender to the named addressee FDA does not review compounded medication for safety or efficacy. www.biomedrelief.com H5RX Before After 121219_SM BioMed H5 topical solution contains the following active ingredients
• Minoxidil fortified with finasteride - Finasteride acts by reducing DHT, thereby inhibiting miniaturiza- tion of hair follicles in patients with Androgenic Al- opecia (AGA). Scalp-applied topical finasteride with minoxidil can be considered for hair density improve- Formula H5 contains ment in combination with or without oral finasteride. multiple active ingredients for increased efficacy. • Azelaic Acid - A naturally occurring substance FDA approved treatments for found in whole grains that contains a mild antibiotic hair loss (Alopecia) designed to reduce harmful bacteria from the skin. It • Minoxidil 10% is also said to be a potential inhibitor of 5-alpha-re- (active ingredient in Rogaine) ductase in human skin. A reduction of this enzyme There are currently two treatments approved • Azelac acid 2% by the FDA for treatment of miniaturization of reduces the amount of DHT in the body and, there- hair-follicles from Androgenic Alopecia (AGA). fore, can have a similar effect to finastride; the active • Ketoconazole 2% ingredient in the FDA approved oral hair loss medi- • Tea tree oil 0.25% • Finasteride (Propecia) - The American Hair cation finasteride. Loss Association notes finasteride is a prescrip- • Finasteride 0.25% 100ml/Cost $89 tion oral treatment for male pattern baldness. It • Ketoconazole - Ketoconazole, an anti-fungal med- (active ingredient in Propecia) 200ml/Cost $149 reportedly reduces the active levels of dihydro- ication, can also be effective in stimulating new hair testosterone (DHT) in the body, therefore, pre- growth for sufferers of Androgenic Alopecia (AGA). venting the miniaturization of hair follicles. Many DHT is the hormone responsible for shrinking hair Results as early as 4-6 weeks men who are prescibed finasteride to be taken follicles in people who have this condition. In addition orally experience significant side effects which to killing fungi, ketoconazole is also helpful in coun- Easily applied to the scalp may reduce quality of life. These side effect may tering the effects of DHT. include loss of libido, erectile dysfunction, hypo- gonadism and gynecomastia. Minimal to no side effects
• Minoxidil - A topical treatment that has been 100% money back guarantee used since the 1990’s to treat baldness in men if no results and women. It reportedly promotes new hair growth by increasing cutaneous blood flow to shrinking hair follicles. This may cause follicles in the telogen phase to shed, which are then re- To get started on Formula H5 placed by thicker hairs in a new anagen phase. Before After 8 Weeks Take the order form on the back Other medications can be effective in the treat- of this flyer to your doctor. ment of alopecia when applied directly to the Actual photos of one of our pharmacist who used scalp. BioMed Specialty Pharmacy offers com- Formula H5 for two months. Or pounded formulas that combine FDA approved medications and alternative therapies creating 1. Visit www.biomedrelief.com a custom product that may treat, prevent and 2. Click the “Prescribe Now”, reverse hair thinning and loss due to Androgenic Alopecia (AGA). then “Hair Loss” button.