Valtrex Refill: Medical Consultation Form
Welcome back? After your initial consultation and Valtrex approval each follow-up consultation, if approved, is only $75.00 and includes Valtrex refill prescriptions good for  1 year (12 months of Valtrex treatment without any further consult fees).  Herpes is a life long condition. There is no cure, but Valtrex is PROVEN to effectively suppress recurrent outbreaks. This service NOT AVAILABLE IN ILLINOIS AND ARKANSAS AND FLORIDA

Please accurately and completely provide the following information in order for a physician to review your record. You must include your Medical Wellness Center Membership Number which was assigned upon approval into the program. 
(If you don't have this available, you can Email us for your membership number.)
FOLLOW UP - MEDICAL HISTORY
Medical Wellness Center Membership Number: 
First and Last Name: 

Date of Birth(MM/DD/YY):                Age: 
SEX Female Male 
 
Did you experience any side effects: YES NO
If yes, have these symptoms resolved? YES NO
If yes, please describe symptoms:
Have there been any changes in your current medical conditions that the consulting Physician should be aware of?
(If yes, be sure to also consult you regular primary care physician, symptoms could be unrelated to current treatment and related to some other condition)
  1. Now you can choose to either receive a written prescription and fill your prescription at any local U.S. pharmacy of your choice 
  2. or have your prescription called into your local  U.S. pharmacy of your choice 
  3. or you can fill your prescription online and purchase Valtrex directly online and have the medication shipped directly to your home from Murray Avenue Apothecary  pharmacy or RXUSA pharmacy:



Receive a written prescription via Mail  for #30  Valtrex 500mg + 11 refills

Choose to have your prescription called into your  local U.S. pharmacy  rather than receiving a prescription by mail. If approved, your prescription will be called into a local US pharmacy of your choice.  We do not call into Internet or foreign pharmacies.  WWW.RXUSA.com or Murray Avenue Apothecary are the the only internet/mail-order pharmacies that we will call a prescription into - these two  independent pharmacies are reliable and dispenses only FDA approved authentic medication. There is no extra charge for this service for refill prescriptions and your credit card will be billed the $75 consultation fee and regular S & H processing fee of $ 9.00.  If you are requesting your prescription to be called into your pharmacy, please enter the complete phone# including area code, name and address of pharmacy where you choose to fill your prescription 

ONLY FILL OUT BELOW LINE IF YOU CHOOSE TO HAVE YOUR PRESCRIPTION FILLED ONLINE by Murray Avenue Apothecary AND THE MEDICATION SHIPPED DIRECTLY TO YOU 

AVAILABLE IN UNITED STATES ONLY 
not available in Arkansas, Illinois, or Florida 

Murray Avenue Apothecary:(formerly Community Drug Pharmacy)
Only if you are choosing to fill your prescription online and have  Murray Avenue Apothecary ship the medication to you check below:
Please check here authorizing Murray Avenue Apothecary to fill your prescription for your Valtrex prescription and ship the medication directly to you.  Your prescription will be forwarded to Murray Avenue Apothecary.  You must contact Murray Avenue Apothecary directly by phone ( 412 421 4996)  or they will try to contact you by phone in order to provide your payment and shipping information. Your  medication will be shipped directly to your shipping address that you provided to the pharmacy and you will be billed by Murray Avenue Apothecary for the medication . Medical Wellness Center will only bill you for the online consultation fee($75.00 + 9.00 S & P)

Only if you are choosing to fill your prescription online and have Murray Avenue Apothecary  ship the medication to you, Indicate your choice of  either  #30 Valtrex 500mg tablets  with 11  refills , # 90 Valtrex 500mg with 3 refills,  or  #30 Valtrex 1000mg with 5 refills (take 1/2 pill per day)

Call the pharmacy directly for pricing -412-421-4996:
# 30 Valtrex 500 mg   with  11 additional refills:    from  Murray Avenue Apothecary 
# 90 Valtrex 500 mg   with  3 additional refills:   from  Murray Avenue Apothecary 
#30 Valtrex  1000 mg    with  5  refill :  from Murray Avenue Apothecary 

RXUSA Pharmacy:  1-800-754-3648
Only if you are choosing to fill your prescription online and have  RXUSA ship the medication to you check below:
Please check here authorizing RXUSA Pharmacy to fill your prescription for your Valtrex prescription and ship the medication directly to you.  Your prescription will be forwarded to RXUSA Pharmacy  You must contact RXUSA  directly by phone (1-800-764-3648)  or they will try to contact you by phone in order to provide your payment and shipping information. Your  medication will be shipped directly to your shipping address that you provided to the pharmacy and you will be billed by RXUSA Pharmacy for the medication.  Medical Wellness Center will only bill you for the online consultation fee($75.00 + 9.00 S & P)

Only if you are choosing to fill your prescription online and have Murray Avenue Apothecary  ship the medication to you, Indicate your choice of  either  #30 Valtrex 500mg tablets  with 11  refills , #90 Valtrex 500mg with 3 refills,  or  #30 Valtrex 1000mg with 5 refills (take 1/2 pill per day)

Call the Pharmacy directly for pricing - 1800-764-3648:
# 30 Valtrex 500 mg   with  11 additional refills:    from  RXUSA Pharmacy 
# 90 Valtrex 500 mg   with  3 additional refills:    from  RXUSA Pharmacy 
#30 Valtrex  1000 mg    with  5  refill :   from  RXUSA Pharmacy 

 
PERSONAL and PAYMENT INFORMATION 
In order to review your consultation, you must provide your full name, a Physical Address (We do NOT accept requests to PO Boxes-) and complete Phone number.
We do NOT accept requests from Illinois or Arkansas or  Florida
FULL NAME:
ADDRESS:
NO PO Boxes - must be physical address
CITY:
STATE:    ZIP CODE 
PHONE(Required):
EMAIL(Required):
Please provide complete email, ie You@domain.com or name@aol.com 
NAME OF CREDIT CARD HOLDER
ENTER CREDIT CARD TYPE:
ENTER CREDIT CARD NUMBER
EXPIRATION DATE(MM/YY):
Enter you credit card 3 digit security number. To find this number turn your card around and on the back on the strip where you sign your name there are some numbers printed. There are either a set of 4 numbers (the last 4 numbers of your credit card) and a set of 3 numbers, or just a set of 3 numbers. The set of 3 numbers is the security number that is necessary in order to process your request.
ENTER 3 Digit Security Code
BILLING ADDRESS:
BILLING ZIP CODE
I, AS THE CREDIT CARD HOLDER, VERIFY THAT I AM SUBMITTING THIS ONLINE-CONSULTATION REQUEST FOR A MEDICAL PRESCRIPTION AND I AUTHORIZE THE CHARGES STATED TO BE MADE TO MY CREDIT CARD (I understand that if I later dispute this charge as "unauthorized" I will be subject to criminal prosecution for credit card fraud). 
If credit card holder name is different than the person submitting consultation, you must verify that you have been given authorization to use this credit card:  I VERIFY THAT I HAVE BEEN GIVEN AUTHORIZATION BY CREDIT CARD HOLDER TO USE ABOVE CREDIT CARD.( I understand that if this charge is disputed by credit card holder as unauthorized, I will be subject to penalties of criminal prosecution for credit card fraud.)YES NO
By submitting this consultation form, I certify:

I am 18 years of age or older.
I have been approved for Valtrex by Medical Wellness Center  Physicians and have been assigned a Membership number.
I have read and agree to Waiver of Liability.
I understand the side effects of this medication and adverse effect.
I do not have any of the contraindications to therapy.
I do not have a current prescription for Valtrex from another physician.
I understand that my credit card will be billed $75.00  ($9.00 S& H)  for this consultation if approved( no refunds for consultation fee given under any conditions), and will provide Valtrex refill Prescriptions good for 12 months.
I understand that no one  under age 18 should take Valtrex. I also understand that if pregnant, potentially pregnant  or nursing women should not take Valtrex.  I understand if I have advanced HIV disease, compromised immune system, or have had any organ transplant I can not take Valtrex.  I also understand that there are no refunds or credits given under any circumstances even if  I later decide not to take the medication for any reason.
I have answered all the questions truthfully. 


Please CONFIRM YOUR SELECTION made above of receiving written Rx, Express Service called into local U.S. pharmacy, or receiving medication from  Murray Avenue Apothecary or RXUSA.com pharmacy:   - 

Receive written prescription by mail in 7-15 days 
Have prescription called into a local U.S. pharmacy within approximately 24 - 72 hours (No extra charge for this service)

Murray Avenue Apothecary ships you the medication to your home # 30 Valtrex 500 mg 11 refills
Murray Avenue Apothecary ships you the medication to your home # 90 Valtrex 500 mg 3 refill
Murray Avenue Apothecary ships you the medication to your home  #30 Valtrex 1000mg 5 refills

RXUSA Pharmacy ships you the medication to your home # 30 Valtrex 500 mg 11 refills
RXUSA Pharmacy ships you the medication to your home #90 Valtrex 500 mg 3 refill
RXUSA Pharmacy ships you the medication to your home  #30 Valtrex 1000mg 5 refills
 
 
 

 

Click SUBMIT button to order Valtrex Refill
You may submit this consultation form (secure server) over the Internet by clicking the SUBMIT button.
 

For any questions & fastest reply contact us by
email at Wellnessmd@yahoo.com
Email to contact Medical Wellness CenterTo contact Medical Wellness Center w ith any questions, please Email us.

 
 
 
PHONE  NUMBER: 
(US ONLY)		 617-367-8887
Medical Wellness Center 
Boston, MA