Hair Loss Preparations Template

Prescription Template

400 Taché Ave, Winnipeg, MB R2H 2A4
Phone: (204) 233-3469 Fax: (204) 231-1739

Patient

Name

DOBSexMF

PHIN

Phone

Date

Compounded Preparations

Check one

Minoxidil 0.625 mg capsules (low-dose oral) — or mg

Minoxidil 5% topical solution

Finasteride 0.25% / minoxidil 5% scalp solution

Finasteride 0.25% / minoxidil 3% scalp solution

Finasteride 1% / hydrocortisone 1% / minoxidil 5% shampoo

Other:

Topical finasteride options are sometimes considered for post-menopausal women under prescriber supervision; oral minoxidil dosing is prescriber-titrated.

Directions

Sig

Quantity Refills

Prescriber

Name	Clinic
Phone	Fax

Signature