Consent for Telehealth Services

Telehealth involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. Telehealth services offered by Barber Surgeons Guild PC, Barber Surgeons PLLC, and Justin Edward Rome MD PC, collectively referred to as the DBA Blends, may include chart review, remote prescribing, appointment scheduling, health information sharing, and non-clinical services, such as patient education. The information you provide may be used for diagnosis, therapy, follow-up and/or patient education, and may include any combination of the following: (1) health records and test results; (2) images and asynchronous communications; (3) live two-way audio and video; (4) interactive audio with store and forward; and (5) secure messaging.

The electronic communication systems we use incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against corruption.

Blends physicians and nurses (our “Providers”) are an addition to, and not a replacement for, your primary care physician. Responsibility for your overall medical care should remain with your local primary care doctor, if you have one, and we strongly encourage you to locate one if you do not.


  • Improved access to care by enabling you to remain in your home while the Blends provider consults, reviews, and treats at distant/other sites.
  • More efficient care evaluation and management.
  • Obtaining expertise of a specialist as appropriate.


  • Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment and technologies.
  • In rare events, our provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth consult or a meeting with your local primary care doctor.
  • In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.
  • In rare events, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

If you need to receive follow-up care, assistance in the event of an adverse reaction to the treatment, or in the event of an inability to communicate as a result of a technological or equipment failure, please contact

By checking the box associated with “Consent for Telehealth Services,” you acknowledge that you understand and agree with the following:

  1. I hereby consent to receiving Blends’ services via telehealth technologies. I understand that Blends and its providers offer telehealth-based medical services, but that these services do not replace the relationship between me and my primary care doctor. I also understand it is up to the Blends provider to determine whether or not my specific clinical needs are appropriate for a telehealth encounter.
  2. I have been given an opportunity to request credentials from the Blends provider.
  3. I understand that federal and state law requires health care providers to protect the privacy and the security of health information. I understand that Blends will take steps to make sure that my health information is not seen by anyone who should not see it. I understand that telehealth may involve electronic communication of my personal medical information to other health practitioners who may be located in other areas, including out of state.
  4. I understand there is a risk of technical failures during the telehealth encounter beyond the control of Blends. I agree to hold harmless Blends for delays in evaluation or for information lost due to such technical failures.
  5. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment. I understand that I may suspend or terminate use of the telehealth services at any time for any reason or for no reason. I understand that if I am experiencing a medical emergency, that I should dial 9-1-1 immediately and that the Blends providers are not able to connect me directly to any local emergency services.
  6. I understand that alternatives to telehealth consultation, such as in-person services are available to me, and in choosing to participate in a telehealth consultation, I understand that some parts of the services involving tests may be conducted by individuals at my location, or at a testing facility, at the direction of the Blends provider (e.g. labs or bloodwork). I also understand that if I seek in-person treatment for hair transplant or other services, I will review and will be asked to accept additional consent terms.
  7. I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
  8. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Persons may be present during the consultation other than the Blends provider in order to operate the telehealth technologies. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telehealth examination; and/or (3) terminate the consultation at any time.
  9. I understand that there is no guarantee that I will be given a prescription at all.
  10. I understand that I have the right to request a copy of my medical records which will be provided to me at reasonable cost of preparation, shipping and delivery.


Blends treatment plans contains information regarding the medication(s) that was prescribed to you including but not limited to: ingredient information, interactions, side effects, how to take the medication(s), how to store the medication(s), and other important information you should know prior to starting the medication(s).

Compounding Information

These are not mass-produced, off the shelf medications, but rather custom formulas recommended by your doctor. These medications have been specially compounded and individualized for you.

Active Ingredients

Your medication may contain one or more of the following ingredients - see your medication label for the actual list of active pharmaceutical ingredients that are included in your medication(s):

  • Finasteride
  • Dutasteride
  • Minoxidil
  • Tretinoin
  • Latanoprost
  • Ketoconazole


This medication(s) may cause an allergic reaction if you are allergic to similar medications or components. If you are allergic to any of the following, please stop the medicine, reach to us and see a doctor.

  • Finasteride
  • Dutasteride
  • Minoxidil
  • Tretinoin
  • Latanoprost
  • Ketoconazole

General Adverse Effects

You may experience side effects with these medications. These side effects are common and may go away with time and daily use. 

  • Itching
  • Redness
  • Dryness
  • Increased sensitivity to the sun

If you are experiencing any other side effects, please reach out to your healthcare provider or pharmacist.


Treating hair loss with this medication could take 3-6 months of appropriate use to see the full effect.

Specific Adverse Effects

  1. For Women:

Women who are pregnant, breastfeeding, or planning to get pregnant should avoid contact with and ingestion of these medications.  Premenopausal women taking these medications should proceed with caution and ensure multiple forms of birth control are being used, and stop using immediately should pregnancy occur.  Specifically, the pharmaceutical ingredients Finasteride and  Dutasteride are considered pregnancy category X, and Minoxidil, Latanoprost, and Ketoconazole are considered pregnancy category C.  While these medications have been shown to be effective in treating hair loss in women, the well documented nature of the side effects around pregnancy must be well understood.  If you have any questions, consult with your healthcare provider.

  1.  For Men:

Medications containing Finasteride and Dutasteride may have men’s health side effects.  Topically compounded versions of these medicines carry a lesser risk of such side effects, however, the following should still be considered: Finasteride and Dutasteride have been shown to decrease blood PSA levels in men, please discuss with your primary healthcare provider prior to starting this medication.  This is especially important for men who are being treated for prostate cancer, or have a personal history, or a strong family history of prostate cancer, as PSA levels are used to help screen for prostate cancer and will be lower in the case of taking these medications.  In rare cases, Finasteride and Dutasteride have been linked to changes in breast tissue.  Advise your healthcare provider immediately if you notice any such changes, and stop taking the medications.  Finasteride and Dutasteride can cause sexual side effects in 1-3% of patients, including but not limited to, decreased libido, and can potentially affect fertility while taking.  Talk to your healthcare provider if you are having any of these symptoms.

  1. Mental Health:

Medications containing Finasteride and Dutasteride can affect mood leading to symptoms such as but not limited to depression, brain fog, and decreased interest levels.  Such symptoms could be amplified in individuals with a history of mental health disorders.  If you have a history of depression or other mental health disorder, discuss with your healthcare provider if this medication is safe for you.  If you have any active symptoms of depression and/or suicidality, or had any such symptoms prior to using these medications, you should not take the medications and talk to your healthcare provider immediately.  While these mental health adverse effects have been reported in men, they may also be a risk for women, even though it is not well documented in the medical literature.


Treating hair loss with this medication(s) often will  take 3-6 months of appropriate use to see the full effect.  Continuous use thereafter is required to best maintain results. To ensure appropriate use, please be sure to follow the directions printed on the label of your medication(s).  Stopping the medication(s) may accelerate hair loss.  If you need to stop the medication(s) for a medical reason, do so.  If you are not having any adverse effects and would still  like to discontinue use, it is recommended that you first speak to your healthcare provider to discuss possible dose and frequency tapering options as well as medication alternatives to help minimize the risk of accelerated hair loss.


  1.  Accurate Information

We have evaluated the specific health information you provided and are making our recommendations based on it. If you forgot to provide or incorrectly provided the information, we may misdiagnose or fail to diagnose conditions that you may have, which could affect our recommendation for treatment. If you need to clarify or update any information about your health, you can message or call us anytime.

  1.  Treatment Failure

This treatment is not 100% effective. It may not work or may only partially resolve the condition for which you are seeking treatment. If the treatment is not working, or if you are experiencing new or worsening symptoms, discuss with your healthcare provider. If you are experiencing an emergency, call 911 or seek immediate medical help in-person. You may need to seek alternative treatment such as those listed below or in the follow-up plan.

  1.  Accepting or declining our recommendation

We are recommending this medication(s)  for you because the potential benefits outweigh the risks, in our estimation. You should evaluate this information and any input from your primary healthcare provider(s), and any other relevant information to decide if this medication(s) is appropriate for you.


Store in a cool, dry place away from light. Do not freeze.

Additional information

Keep all medications in a safe place, and away from children.  Should accidental exposure or ingestion occur by a child, seek immediate care with a healthcare professional.

In addition, keep all medications away from pets..  Should accidental exposure or ingestion occur, seek immediate care with a veterinarian.

Do not use this medication(s) past the use by date provided on the medication’s  label.  Do not throw away unused or expired drugs. Do not flush down the toilet or pour down the drain unless you are told to do so by your healthcare provider. Check with your pharmacist if you have questions on the best way to dispose of your medication. There may be take-back programs in your area. 

Instructions for Use

Compounded topical medications are for external use only – avoid contact with your face, eyes, lips, and mouth. 

To Apply Topical:

  • Always, follow your doctor's instructions on how to apply the topical compound.
  • Before applying this medicine, make sure your hair and scalp are completely dry.
  • Part the hair to expose the scalp and massage in a very thin coat of the topical compound with your fingers.
  • Repeat in all areas of hair thinning until the amount prescribed has been fully used.
  • Do not shampoo your hair for 4 hours after applying.
  • Immediately wash your hands after using this topical compound.
  • Let air dry. DO NOT use a hairdryer to dry the scalp after you apply.
  • Allow 2 to 4 hours to fully set in, otherwise the topical compound may stain clothing or linens.  Avoid touching during this time, as it may transfer the topical compound to other areas.


If your symptoms or health problems do not get better or if they become worse, call your doctor. ;  Do not share your drugs with others and do not take anyone else's drugs.;  Some drugs may have another patient information leaflet. Check with your pharmacist. If you have any questions about this drug, please talk with your doctor, nurse, pharmacist, or other health care provider.;  If you think there has been an overdose, call your poison control center or get medical care right away. Be ready to tell or show what was taken, how much, and when it happened.

Patient Consent for telehealth services:

By clicking the box labeled “Sonsent for the telehealth”, I hereby give my informed consent to participate in telehealth consultations under the terms described herein, and furthermore, I attest to have 

I have read this document carefully, and understand the risks and benefits of telehealth consultations and the medications used by Blends Providers in the treatment of hair loss,  and I have had any questions regarding the treatments explained to my satisfaction.