Xpress Health Urgent Care / Berkley Urgent Care / Express Health Urgent Care Nutrafol® Hair Growth Supplement Consent & Advisory Form

Purpose

Nutrafol® is a dietary supplement formulated to support healthier, thicker-looking hair by addressing factors that may contribute to hair thinning, including stress, nutrition, metabolism, hormones, and aging. Results vary among individuals and are not guaranteed.

Patient Acknowledgment

1. Dietary Supplement
Nutrafol® is a dietary supplement and is not intended to diagnose, treat, cure, or prevent any disease.

2. Expected Results
Results vary from person to person. Most individuals may require 3–6 months of consistent use before noticeable improvement occurs. No specific outcome or degree of hair regrowth can be guaranteed.

3. Possible Side Effects
Potential side effects may include upset stomach, nausea, bloating, diarrhea, constipation, headache, allergic reactions, or skin/scalp changes.

4. Medication and Supplement Interactions
Patients should disclose all medications, supplements, and medical conditions before use.

5. Blood Thinners, Bleeding Risk, and Surgery

Certain ingredients may affect blood clotting or increase bleeding risk in some individuals. Patients taking anticoagulant or antiplatelet medications, including warfarin, apixaban, rivaroxaban, dabigatran, clopidogrel, or daily aspirin therapy should consult their healthcare provider before starting Nutrafol®. Patients should inform their surgeon or procedural provider that they are taking Nutrafol® before any surgery, dental procedure, or invasive procedure. The clinic recommends
discontinuing Nutrafol® at least 1–2 weeks before a planned procedure unless otherwise directed by the treating physician or surgeon.

6. Pregnancy and Breastfeeding
Nutrafol® is generally not recommended during pregnancy or breastfeeding unless approved by a healthcare provider.

7. Medical Evaluation
Hair loss may result from underlying medical conditions and Nutrafol® does not replace appropriate medical evaluation or treatment.

8. Financial Responsibility
Nutrafol® is typically not covered by insurance. All purchases are voluntary. Opened products may not be eligible for return or refund per clinic policy.

Patient Consent
I have read and understand the information above. I have had the opportunity to ask questions and have received satisfactory answers. I voluntarily choose to purchase and/or use Nutrafol® and understand that results cannot be guaranteed.