{"id":21985,"date":"2026-02-22T02:03:22","date_gmt":"2026-02-22T08:03:22","guid":{"rendered":"https:\/\/northwesternhair.com\/?page_id=21985"},"modified":"2026-02-22T02:04:23","modified_gmt":"2026-02-22T08:04:23","slug":"rx2","status":"publish","type":"page","link":"https:\/\/northwesternhair.com\/de\/rx2\/","title":{"rendered":"rx2"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"21985\" class=\"elementor elementor-21985\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-5ccde0f e-flex e-con-boxed e-con e-parent\" data-id=\"5ccde0f\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-f313ec7 elementor-widget elementor-widget-html\" data-id=\"f313ec7\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<!-- Note :\n   - You can modify the font style and form style to suit your website. \n   - Code lines with comments Do not remove this code are required for the form to work properly, make sure that you do not remove these lines of code. \n   - The Mandatory check script can modified as to suit your business needs. \n   - It is important that you test the modified form before going live.-->\n<div id = 'crmWebToEntityForm' class = 'zcwf_lblLeft crmWebToEntityForm' style = 'background-color: white;color: black;max-width: 600px;'>\n\t<meta name = 'viewport' content = 'width=device-width, initial-scale=1.0'>\n\t\t<META HTTP-EQUIV = 'content-type' CONTENT = 'text\/html;charset=UTF-8'>\n\t\t\t<form id = 'webform7174119000001628811' action = 'https:\/\/crm.zoho.com\/crm\/WebToContactForm' name = WebToContacts7174119000001628811 method = 'POST' onSubmit = 'javascript:document.charset=\"UTF-8\"; return checkMandatory7174119000001628811()' accept-charset = 'UTF-8'>\n\t\t\t\t<input type = 'text' style = 'display:none;' name = 'xnQsjsdp' value = '4a0688342223584360c3a5a64f73a72d7ac94e28bfb7c0c5fab518228cb69943'>\n\t\t\t\t<\/input>\n\t\t\t\t<input type = 'hidden' name = 'zc_gad' id = 'zc_gad' value = ''>\n\t\t\t\t<\/input>\n\t\t\t\t<input type = 'text' style = 'display:none;' name = 'xmIwtLD' value = '906783df3dc169b910d9c9674e0a107897b0b04a3a88d6aed8e8f53cbc9844aff3788e208bf79bfb4ec21858776fffea'>\n\t\t\t\t<\/input>\n\t\t\t\t<input type = 'text' style = 'display:none;' name = 'actionType' value = 'Q29udGFjdHM='>\n\t\t\t\t<\/input>\n\t\t\t\t<input type = 'text' style = 'display:none;' name = 'returnURL' value = 'null'>\n\t\t\t\t<\/input>\n\t\t\t\t<!-- Do not remove this code. -->\n\t\t\t\t<style>\n\t\t\t\t\thtml,body{\n\t\t\t\t\t\tmargin: 0px;\n\t\t\t\t\t}\n\t\t\t\t\t.formsubmit.zcwf_button{\n\t\t\t\t\t\tcolor: white !important;\n\t\t\t\t\t\tbackground: transparent linear-gradient(0deg, #0279FF 0%, #00A3F3 100%);\n\t\t\t\t\t}\n\t\t\t\t\t#crmWebToEntityForm.zcwf_lblLeft{\n\t\t\t\t\t\twidth: 100%;\n\t\t\t\t\t\tpadding: 25px;\n\t\t\t\t\t\tmargin: 0 auto;\n\t\t\t\t\t\tbox-sizing: border-box;\n\t\t\t\t\t}\n\t\t\t\t\t#crmWebToEntityForm.zcwf_lblLeft *{\n\t\t\t\t\t\tbox-sizing: border-box;\n\t\t\t\t\t}\n\t\t\t\t\t#crmWebToEntityForm {text-align: left;\n\t\t\t\t\t}\n\t\t\t\t\t#crmWebToEntityForm *{\n\t\t\t\t\tdirection: ltr;\n\t\t\t\t\t}\n\t\t\t\t\t.zcwf_lblLeft .zcwf_title{\n\t\t\t\t\tword-wrap: break-word;\n\t\t\t\t\tpadding: 0px 6px 10px;\n\t\t\t\t\tfont-weight: bold }\n\t\t\t\t\t.zcwf_lblLeft.cpT_primaryBtn:hover{\n\t\t\t\t\tbackground: linear-gradient(#02acff 0,#006be4 100%)no-repeat padding-box !important;\n\t\t\t\t\tbox-shadow: 0 -2px 0 0  #0159b9 inset !important;\n\t\t\t\t\tborder: 0 !important;\n\t\t\t\t\tcolor:  #fff !important;\n\t\t\t\t\toutline: 0 !important;\n\t\t\t\t\t}\n\t\t\t\t\t.zcwf_lblLeft .zcwf_col_fld input[ type  = text], input[ type  = password], .zcwf_lblLeft .zcwf_col_fld textarea{\n\t\t\t\t\twidth: 60%;\n\t\t\t\t\tborder: 1px solid  #c0c6cc !important;\n\t\t\t\t\tresize: vertical;\n\t\t\t\t\tborder-radius: 2px;\n\t\t\t\t\tfloat: left;\n\t\t\t\t\t}\n\t\t\t\t\t.zcwf_lblLeft .zcwf_col_lab{\n\t\t\t\t\twidth: 30%;\n\t\t\t\t\tword-break: break-word;\n\t\t\t\t\tpadding: 0px 6px 0px;\n\t\t\t\t\tmargin-right: 10px;\n\t\t\t\t\tmargin-top: 5px;\n\t\t\t\t\tfloat: left;\n\t\t\t\t\tmin-height: 1px;\n\t\t\t\t\t}\n\t\t\t\t\t.zcwf_lblLeft .zcwf_col_fld{\n\t\t\t\t\tfloat: left;\n\t\t\t\t\twidth: 68%;\n\t\t\t\t\tpadding: 0px 6px 0px;\n\t\t\t\t\tposition: relative;\n\t\t\t\t\tmargin-top: 5px;\n\t\t\t\t\t}\n\t\t\t\t\t.zcwf_lblLeft .zcwf_privacy {padding: 6px;\n\t\t\t\t\t}\n\t\t\t\t\t.zcwf_lblLeft .wfrm_fld_dpNn {display: none;\n\t\t\t\t\t}\n\t\t\t\t\t.dIB {display: inline-block;\n\t\t\t\t\t}\n\t\t\t\t\t.zcwf_lblLeft .zcwf_col_fld_slt{\n\t\t\t\t\twidth: 60%;\n\t\t\t\t\tborder: 1px solid  #ccc;\n\t\t\t\t\tbackground:  #fff;\n\t\t\t\t\tborder-radius: 4px;\n\t\t\t\t\tfont-size: 12px;\n\t\t\t\t\tfloat: left;\n\t\t\t\t\tresize: vertical;\n\t\t\t\t\tpadding: 2px 5px;\n\t\t\t\t\t}\n\t\t\t\t\t.zcwf_lblLeft .zcwf_row:after, .zcwf_lblLeft .zcwf_col_fld:after{\n\t\t\t\t\tcontent: '';\n\t\t\t\t\tdisplay: table;\n\t\t\t\t\tclear: both;\n\t\t\t\t\t}\n\t\t\t\t\t.zcwf_lblLeft .zcwf_col_help{\n\t\t\t\t\tfloat: left;\n\t\t\t\t\tmargin-left: 7px;\n\t\t\t\t\tfont-size: 12px;\n\t\t\t\t\tmax-width: 35%;\n\t\t\t\t\tword-break: break-word;\n\t\t\t\t\t}\n\t\t\t\t\t.zcwf_lblLeft .zcwf_help_icon{\n\t\t\t\t\tcursor: pointer;\n\t\t\t\t\twidth: 16px;\n\t\t\t\t\theight: 16px;\n\t\t\t\t\tdisplay: inline-block;\n\t\t\t\t\tbackground:  #fff;\n\t\t\t\t\tborder: 1px solid  #c0c6cc;\n\t\t\t\t\tcolor:  #c1c1c1;\n\t\t\t\t\ttext-align: center;\n\t\t\t\t\tfont-size: 11px;\n\t\t\t\t\tline-height: 16px;\n\t\t\t\t\tfont-weight: bold;\n\t\t\t\t\tborder-radius: 50%;\n\t\t\t\t\t}\n\t\t\t\t\t.zcwf_lblLeft .zcwf_row {margin: 15px 0px;\n\t\t\t\t\t}\n\t\t\t\t\t.zcwf_lblLeft .formsubmit{\n\t\t\t\t\tmargin-right: 5px;\n\t\t\t\t\tcursor: pointer;\n\t\t\t\t\tcolor:  #313949;\n\t\t\t\t\tfont-size: 12px;\n\t\t\t\t\t}\n\t\t\t\t\t.zcwf_lblLeft .zcwf_privacy_txt{\n\t\t\t\t\twidth: 90%;\n\t\t\t\t\tcolor: rgb(0, 0, 0);\n\t\t\t\t\tfont-size: 12px;\n\t\t\t\t\tfont-family: Arial;\n\t\t\t\t\tdisplay: inline-block;\n\t\t\t\t\tvertical-align: top;\n\t\t\t\t\tcolor:  #313949;\n\t\t\t\t\tpadding-top: 2px;\n\t\t\t\t\tmargin-left: 6px;\n\t\t\t\t\t}\n\t\t\t\t\t.zcwf_lblLeft .zcwf_button{\n\t\t\t\t\tfont-size: 12px;\n\t\t\t\t\tcolor:  #313949;\n\t\t\t\t\tborder: 1px solid  #c0c6cc;\n\t\t\t\t\tpadding: 3px 9px;\n\t\t\t\t\tborder-radius: 4px;\n\t\t\t\t\tcursor: pointer;\n\t\t\t\t\tmax-width: 120px;\n\t\t\t\t\toverflow: hidden;\n\t\t\t\t\ttext-overflow: ellipsis;\n\t\t\t\t\twhite-space: nowrap;\n\t\t\t\t\t}\n\t\t\t\t\t.zcwf_lblLeft .zcwf_tooltip_over{\n\t\t\t\t\tposition: relative;\n\t\t\t\t\t}\n\t\t\t\t\t.zcwf_lblLeft .zcwf_tooltip_ctn{\n\t\t\t\t\tposition: absolute;\n\t\t\t\t\tbackground:  #dedede;\n\t\t\t\t\tpadding: 3px 6px;\n\t\t\t\t\ttop: 3px;\n\t\t\t\t\tborder-radius: 4px;\n\t\t\t\t\tword-break: break-word;\n\t\t\t\t\tmin-width: 100px;\n\t\t\t\t\tmax-width: 150px;\n\t\t\t\t\tcolor:  #313949;\n\t\t\t\t\tz-index: 100;\n\t\t\t\t\t}\n\t\t\t\t\t.zcwf_lblLeft .zcwf_ckbox{\n\t\t\t\t\tfloat: left;\n\t\t\t\t\t}\n\t\t\t\t\t.zcwf_lblLeft .zcwf_file{\n\t\t\t\t\twidth: 55%;\n\t\t\t\t\tbox-sizing: border-box;\n\t\t\t\t\tfloat: left;\n\t\t\t\t\t}\n\t\t\t\t\t.cBoth:after{\n\t\t\t\t\tcontent: '';\n\t\t\t\t\tdisplay: block;\n\t\t\t\t\tclear: both;\n\t\t\t\t\t}\n\t\t\t\t\t@media all and  (max-width: 600px){\n\t\t\t\t\t.zcwf_lblLeft .zcwf_col_lab, .zcwf_lblLeft .zcwf_col_fld{\n\t\t\t\t\twidth: auto;\n\t\t\t\t\tfloat: none !important;\n\t\t\t\t\t}\n\t\t\t\t\t.zcwf_lblLeft .zcwf_col_help {width: 40%;\n\t\t\t\t\t}\n\t\t\t\t\t}\n\t\t\t\t<\/style>\n\t\t\t\t<div class = 'zcwf_row'>\n\t\t\t\t\t<div class = 'zcwf_col_lab' style = 'font-size:12px; font-family: Arial;'>\n\t\t\t\t\t\t<label for = 'First_Name'>First Name\n\t\t\t\t\t\t\t<span style = 'color:red;'>*<\/span>\n\t\t\t\t\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class = 'zcwf_col_fld'>\n\t\t\t\t\t\t<input type = 'text' id = 'First_Name' aria-required = 'true' aria-label = 'First Name' name = 'First Name' aria-valuemax = '40' maxlength = '40'>\n\t\t\t\t\t\t<\/input>\n\t\t\t\t\t\t<div class = 'zcwf_col_help'>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class = 'zcwf_row'>\n\t\t\t\t\t<div class = 'zcwf_col_lab' style = 'font-size:12px; font-family: Arial;'>\n\t\t\t\t\t\t<label for = 'Last_Name'>Last Name\n\t\t\t\t\t\t\t<span style = 'color:red;'>*<\/span>\n\t\t\t\t\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class = 'zcwf_col_fld'>\n\t\t\t\t\t\t<input type = 'text' id = 'Last_Name' aria-required = 'true' aria-label = 'Last Name' name = 'Last Name' aria-valuemax = '80' maxlength = '80'>\n\t\t\t\t\t\t<\/input>\n\t\t\t\t\t\t<div class = 'zcwf_col_help'>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class = 'zcwf_row'>\n\t\t\t\t\t<div class = 'zcwf_col_lab' style = 'font-size:12px; font-family: Arial;'>\n\t\t\t\t\t\t<label for = 'Email'>Email\n\t\t\t\t\t\t\t<span style = 'color:red;'>*<\/span>\n\t\t\t\t\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class = 'zcwf_col_fld'>\n\t\t\t\t\t\t<input type = 'text' ftype = 'email' autocomplete = 'false' id = 'Email' aria-required = 'true' aria-label = 'Email' name = 'Email' aria-valuemax = '100' crmlabel = '' maxlength = '100'>\n\t\t\t\t\t\t<\/input>\n\t\t\t\t\t\t<div class = 'zcwf_col_help'>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class = 'zcwf_row'>\n\t\t\t\t\t<div class = 'zcwf_col_lab' style = 'font-size:12px; font-family: Arial;'>\n\t\t\t\t\t\t<label for = 'Phone'>Phone\n\t\t\t\t\t\t\t<span style = 'color:red;'>*<\/span>\n\t\t\t\t\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class = 'zcwf_col_fld'>\n\t\t\t\t\t\t<input type = 'text' id = 'Phone' aria-required = 'true' aria-label = 'Phone' name = 'Phone' aria-valuemax = '50' maxlength = '50'>\n\t\t\t\t\t\t<\/input>\n\t\t\t\t\t\t<div class = 'zcwf_col_help'>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class = 'zcwf_row'>\n\t\t\t\t\t<div class = 'zcwf_col_lab' style = 'font-size:12px; font-family: Arial;'>\n\t\t\t\t\t\t<label for = 'CONTACTCF8'>Birthdate\n\t\t\t\t\t\t\t<span style = 'color:red;'>*<\/span>\n\t\t\t\t\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class = 'zcwf_col_fld'>\n\t\t\t\t\t\t<input type = 'text' id = 'CONTACTCF8' aria-required = 'true' aria-label = 'CONTACTCF8' name = 'CONTACTCF8' aria-valuemax = '255' maxlength = '255'>\n\t\t\t\t\t\t<\/input>\n\t\t\t\t\t\t<div class = 'zcwf_col_help'>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class = 'zcwf_row'>\n\t\t\t\t\t<div class = 'zcwf_col_lab' style = 'font-size:12px; font-family: Arial;'>\n\t\t\t\t\t\t<label for = 'CONTACTCF7'>Allergies\n\t\t\t\t\t\t\t<span style = 'color:red;'>*<\/span>\n\t\t\t\t\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class = 'zcwf_col_fld'>\n\t\t\t\t\t\t<input type = 'text' id = 'CONTACTCF7' aria-required = 'true' aria-label = 'CONTACTCF7' name = 'CONTACTCF7' aria-valuemax = '255' maxlength = '255'>\n\t\t\t\t\t\t<\/input>\n\t\t\t\t\t\t<div class = 'zcwf_col_help'>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class = 'zcwf_row'>\n\t\t\t\t\t<div class = 'zcwf_col_lab' style = 'font-size:12px; font-family: Arial;'>\n\t\t\t\t\t\t<label for = 'CONTACTCF22'>Gender<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class = 'zcwf_col_fld'>\n\t\t\t\t\t\t<select class = 'zcwf_col_fld_slt' role = 'combobox' aria-expanded = 'false' aria-haspopup = 'listbox' id = 'CONTACTCF22' onChange = 'addAriaSelected7174119000001628811()' aria-required = 'false' aria-label = 'CONTACTCF22' name = 'CONTACTCF22'>\n\t\t\t\t\t\t\t<option value = '-None-'>-None-<\/option>\n\t\t\t\t\t\t\t<option value = 'Male&#x20;-'>Male -<\/option>\n\t\t\t\t\t\t\t<option value = 'Female'>Female<\/option>\n\t\t\t\t\t\t<\/select>\n\t\t\t\t\t\t<div class = 'zcwf_col_help'>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class = 'zcwf_row'>\n\t\t\t\t\t<div class = 'zcwf_col_lab' style = 'font-size:12px; font-family: Arial;'>\n\t\t\t\t\t\t<label for = 'Mailing_Street'>Mailing Street\n\t\t\t\t\t\t\t<span style = 'color:red;'>*<\/span>\n\t\t\t\t\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class = 'zcwf_col_fld'>\n\t\t\t\t\t\t<input type = 'text' id = 'Mailing_Street' aria-required = 'true' aria-label = 'Mailing Street' name = 'Mailing Street' aria-valuemax = '250' maxlength = '250'>\n\t\t\t\t\t\t<\/input>\n\t\t\t\t\t\t<div class = 'zcwf_col_help'>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class = 'zcwf_row'>\n\t\t\t\t\t<div class = 'zcwf_col_lab' style = 'font-size:12px; font-family: Arial;'>\n\t\t\t\t\t\t<label for = 'Mailing_City'>Mailing City\n\t\t\t\t\t\t\t<span style = 'color:red;'>*<\/span>\n\t\t\t\t\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class = 'zcwf_col_fld'>\n\t\t\t\t\t\t<input type = 'text' id = 'Mailing_City' aria-required = 'true' aria-label = 'Mailing City' name = 'Mailing City' aria-valuemax = '100' maxlength = '100'>\n\t\t\t\t\t\t<\/input>\n\t\t\t\t\t\t<div class = 'zcwf_col_help'>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class = 'zcwf_row'>\n\t\t\t\t\t<div class = 'zcwf_col_lab' style = 'font-size:12px; font-family: Arial;'>\n\t\t\t\t\t\t<label for = 'Mailing_State'>Mailing State\n\t\t\t\t\t\t\t<span style = 'color:red;'>*<\/span>\n\t\t\t\t\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class = 'zcwf_col_fld'>\n\t\t\t\t\t\t<input type = 'text' id = 'Mailing_State' aria-required = 'true' aria-label = 'Mailing State' name = 'Mailing State' aria-valuemax = '100' maxlength = '100'>\n\t\t\t\t\t\t<\/input>\n\t\t\t\t\t\t<div class = 'zcwf_col_help'>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class = 'zcwf_row'>\n\t\t\t\t\t<div class = 'zcwf_col_lab' style = 'font-size:12px; font-family: Arial;'>\n\t\t\t\t\t\t<label for = 'Mailing_Zip'>Mailing Zip\n\t\t\t\t\t\t\t<span style = 'color:red;'>*<\/span>\n\t\t\t\t\t\t<\/label>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class = 'zcwf_col_fld'>\n\t\t\t\t\t\t<input type = 'text' id = 'Mailing_Zip' aria-required = 'true' aria-label = 'Mailing Zip' name = 'Mailing Zip' aria-valuemax = '30' maxlength = '30'>\n\t\t\t\t\t\t<\/input>\n\t\t\t\t\t\t<div class = 'zcwf_col_help'>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class = 'zcwf_row'>\n\t\t\t\t\t<div class = 'zcwf_col_lab' style = 'font-size:12px; font-family: Arial;'>\n\t\t\t\t\t\t<label for = 'CONTACTCF1'>Pharmacy Name\n\t\t\t\t\t\t\t<span style = 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