Aczone Gel REFILL Doctor consultation

Aczone Gel REFILL Medical Consultation Form

Aczone Gel dapsone Online Prescriptions for Acne

Welcome back. After you initial consultation and Aczone� Gel depending on your response to 12 weeks of therapy, you can receive a Aczone� Gel prescription with 6 refills. If approved, the refill consultation is only $75.00 plus $9.50 handling and processing fee. There is no extra charge for your prescription to be called into any local United States pharmacy of your choice. Your Medical Wellness Center membership number assigned upon approval into the program is required. If you do not have this available, you can Email us for your membership number. Please fill in all fields and respond to all questions honestly and completely so that a physician can review your refill consultation and prescribe Aczone� Gel. if approved. If the consulting physician determines that Aczone� Gel. is no longer appropriate for you, there is NO charge for this consultation. Available in the United States Only.
Not available in Arkansas, Illinois or Florida In order for Medical Wellness Center's Physicians to provide you with the best care you need to reply honesty to all questions and you need to understand any and all risks and side effects associated with Aczone� Gel. Please be sure to read Aczone� Gel CONTRAINDICATIONS, WARNINGS & SIDE-EFFECTS and confirm that you do NOT have any contraindications, understand the warnings and agree to the Waiver of Liability before filling out this consultation. Failure to answer truthfully and completely could result in serious consequences !
Click here to read all the above stated conditions before filling out the medical consultation form: I have read the previous Aczone� Gel Pages and I do NOT have any of the stated contraindications. I understand the WARNINGS and I have read and agree to the Waiver of Liability:YESNO

The medical information you supply is subject to ALL patient/doctor privilege laws.

**MEDICAL HISTORY**
First and Last Name: Medical Wellness Center Membership Number: SEX: FemaleMale Date of Birth(MM/DD/YY): Current Age: Height (inches): Weight:

Please describe the effect Aczone� Gel Gel had for you:

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)

CLICK HEREYou can choose to have your Aczone� Gel prescription plus 6 refills called into the pharmacy rather than receiving a prescription by mail. 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.

We offer complementary call in service at no extra charge, just the standard service fee of $9.50 and your prescription will be called in approximately 3 -7 days. Or your can choose express processing and your prescription will be called in to your pharmacy in approximately 24 hours or less.
Please check here if your are selecting EXPRESS 24 hours service - $20 express processing fee

Please list all current Medical Conditions:

Do you take any prescription medication?YESNO
If YES, please list all Prescription Medications you are currently taking and the length of time taking each of them: For example: Claritin -4yrs; Zoloft- 6mo,etc.

Please list all over-the-counter drugs you take regularly and why.
For example: aspirin -for migraines, Unisom -difficulty sleeping etc.

Do you have any known allergies to Medicines?YES NO
If Yes, please list any known Allergies to Medicines:

Are you currently Pregnant or Breast-feeding? YES NO
Are you currently trying to become pregnant? YES NO
Have you been diagnosed with G6PD Deficiency - Glucose -6-phosphate dehydrogenase deficiency ? YES NO
Are you currently taking Trimethoprim-Sulfomethoxazole? YES NO
Are you currently using any topical PRESCRIPTION medications on your face?YES NO If yes, please explain:
Are you currently being treated with Accutane, Renova, Retin-A, Retin-A Micro, Tretinoin, Retinol, isotrentinoin or an other Vitamin A product?YES NO If yes, please detail what medication you are using, how long and why you are using it?:
Are you currently using any topical antibiotic prescriptions such as erythromycin or clindamycin , Delacin-T, Cleocin-T?YES NO If yes, please list:
Are you currently using any skin products containing sulfur, resorcinol or salicylic acid?YES NO If yes, please list products using:
Are you allergic to any creams or lotions or skin care products?YES NO If yes, please explain:
Do you have any pre-existing or chronic skin disorders such as but not limited to eczema, seborrheic dermatitis or psoriasis? YES NO If yes, please describe your condition, how long, severity and location:
Do you have very sensitive skin?YES NO If yes, please how sensitive your skin is:
Is your skin frequently red or irritated? YES NO If yes, please explain:
Are you extremely sensitive to the sun? YES NO
Have you undergone Laser Resurfacing or facial laser or photo therapy or a Medically administered glycolic or chemical peel in the last 6 months? YES NO
Please list any plastic surgery, laser or medical peels or cosmetic procedure you have had in your lifetime on your face and when these procedures were done:
DO YOU CURRENTLY TAKE ANY OF THE FOLLOWING MEDICATION? Benzoyl peroxide topicals like Pan OxylYES NO Topical Antibiotics - Cleocin-T, Dalacin-T, erythromycin or clindamycin?YES NO Topical preparations containing sulfur, resorcinol or salicylic acid? YES NO RenovaYES NO Vaniqa CreamYES NO Accutane, Retin-A or Vitamin A skin cream?YES NO

Have you had a physical exam in the last two years? YES NO
Are you currently taking steroids? YES NO
	Do you smoke?YES NO
Do you consume more than 2 servings of alcohol per day? YES NO
Have you had surgery in the last 3 months? YES NO If yes, please explain:
Are you currently being treated for cancer? YES NO If yes, please explain:

CURRENT MEDICAL CONDITIONS & PAST MEDICAL HISTORY
Do you have or have you ever had any of the following conditions?
Kidney Disease	Liver disease	Sebborheic Dermatitis
Eczema	Skin Disease	Psoriasis
Skin Cancer	Mental Illness	Depression
Organ Transplant	Seizures	Anxiety
Coronary Artery Disease	Heart Attack	Heart disease
High Blood Pressure	Stroke	Diabetes
Thyroid Disease	Adrenal Disease	Endocrine Disorders

Do you consider anything in your medical history to be relevant, please give details.
If unsure, please ask your regular doctor

FAMILY HISTORY:
Do any of your immediate family members have any of the following medical problems?
Acne	Liver Disease	Stroke
Eczema	Skin Diseases	Skin Cancer
High blood pressure	Heart disease	Diabetes
Kidney Disease	Gallbladder disease	Cancer
Are there any other diseases than run in your family?
Do any of your family members suffer from acne? If yes describe the relation and the severity of the acne:

Acne Skin History

Have you diagnosed with acne in the past by a physician in the past?Yes No

Have you been treated for acne the past?Yes No
If yes, please list types of treatment for acne you've received in the past:

Are you currently on any treatment regimen for you acne -both over the counter and prescription products?Yes No
If yes, please list types of treatment for acne you are currently receiving:

Please describe what your daily skin care regimen is.

Do you have a family history of acne? YES NO
If yes, please explain:

At what age did you first experience acne?

Please describe your acne condition. Describe areas of the body affected and severity. How long you've suffered with acne? Are the outbreaks decreasing or increasing in severity?.

Please check the photo that best describes the extent of your Acne condition:
Grade I: Mostly comedians - blackheads and whiteheads Grade II: Comedones, papules - blackheads, whiteheads & pimples Grade III: Comedones, papules, pustules & few nodules Grade IV: Comedones, papules, PUSTULES AND CYSTS!
Grade I	Grade II	Grade III	GradeIV

**PERSONAL and PAYMENT INFORMATION**
**Available in the United States Only**
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:
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

AVAILABLE IN UNITED STATES ONLY
Services not available in Arkansas, Illinois, or Florida
Medical Wellness Center does not sell or dispense any medications and we are not affiliated with any pharmacies.
For pricing and price comparisons, you need to contact the pharmacy directly.

Now you can choose either to receive a written prescription by mail which you can fill at your local United States pharmacy, or to have your prescription called into your local United States pharmacy.

For refill prescriptions you have the option of:

1. Receiving a WRITTEN prescription by mail which you can fill at most any local United States pharmacy of your choice (approximately 7- 15 days)
2. Have your prescription called into your local U.S. pharmacy at NO EXTRA charge in 3 - 7 days - COMPLEMENTARY call in service.

If you select option # 2, you can also select EXPRESS 24 hour processing where your prescription will be called into your local pharmacy in approximately 24 hours. If you select EXPRESS 24 hour processing you will be charged a $20 express processing service fee rather than the regular processing fee of $9.50.
Please check here if your are selecting EXPRESS 24 hours service - $20 express processing fee

Check only ONE of the three choices below:

1. Receive Written prescription:
Receive written prescription in approximately 7- 15 days which you can fill at most any local United States pharmacy of your choice.
2. Prescription called into your local pharmacy:
Prescription for one year of refills called into any major local United States pharmacy of your choice rather than receiving a written prescription by mail. If approved, your prescription will be called into a pharmacy of your choice. There is no extra charge for this service for refill prescriptions (unless you are choosing the Express Refill call in service) and your credit card will be billed the $75 consultation fee and regular S & H processing fee of $ 9.50. 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 (The prescription can only be called into your local U.S. pharmacy. It can not be called in, faxed or filled at an internet pharmacy, foreign pharmacy, Canadian pharmacy or pharmacies such as Drugstore.com or an internet version of a local pharmacy such as CVS.com etc.)

Name, complete Phone # including area code, Address of your Pharmacy:

Please CONFIRM YOUR SELECTION made above of receiving written prescription or your prescription called into a local U.S. pharmacy:

Option 1: Receive written prescription by mail in 7-15 days.
Option 2: Prescription called into a local U.S. pharmacy. Please confirm pharmacy phone # belo
Name, complete Phone # including area code

If you are choosing Option 2 to have your prescription called into your local pharmacy , please confirm selection of whether you want Regular service or Express service.

Regular Service: No extra charge, regular processing fee of $9.50: Prescription called into your pharmacy in 3-7 days- complementary.
Express Service: $20 express processing fee instead of the $9.50 regular processing fee- your prescription will be called into your local pharmacy or faxed to in approximately 24 hours or less.

By submitting this consultation form, I certify:

I am am an adult 18 years of age or older.
I have read and agree to Waiver of Liability.
I understand the side effects of this medication include redness, peeling, dryness or oiliness. If you experience Blistering, Crusting, Swelling, Excessive redness or peeling of your skin CHECK WITH YOUR DOCTOR AS SOON AS POSSIBLE!
I understand that Aczone� Gel is for TOPICAL use only. Avoid eyes, angles of the nose, mucous membranes.
I understand that pregnant and nursing mothers should NOT use Aczone� Gel, and I agree not to use Aczone� Gel if I am trying to get pregnant.
I understand that Aczone� Gel gel contains dapsone and this may have an effect on hemolysis and hemoylitic anemia in individual with Glucose -6-phosphate dehydrogenase deficiency and it should not be used unless under direct physician supervision.

I understand that I am NOT to use Benzoyl Peroxide on my face at the same time I using Aczone� Gel, it can cause a yellow discoloration. I understand not to use alpha hydroxy, hydroxy or glycolic containing products. I also understand that I am not to use any facial products that may be drying or irritating to the skin while using Aczone� Gel..
I understand that I am NOT to use any topical products containing sulfur, resorcinol or salicylic acid while using Aczone� Gel.
I understand that I am NOT to use any abrasive soaps, astringents, alcohol-containing skin products on my skin while using Aczone� Gel.
I understand that I am NOT to use any oil-based cosmetics or moisturizers. All cosmetics and moisturizers must be noncomedogenic or nonacnegenic.
I do not have any of the contraindications to therapy, I do not have eczema, sebborheic dermatitis or any chronic skin condition, and I have read and understand the contraindications and possible side effects
I do not have a current prescription for Aczone� Gel from another physician. Medical Wellness Center does NOT fill prescriptions issued by other physicians nor do we sell or dispense medication.
I understand that my credit card will be billed $75.00 and $9.50 or $20 Express S & H for the refill medical consultation if approved (no refunds for this consultation service), if not approved there is no charge. I understand that by submitting this form I agree to pay the $75.00 consultation fee plus S & H processing fee if approved and understand that there are no refunds for any circumstances even if I later change my mind and decide not to take the medication for any reason. I understand that once I submit my consultation for review there are absolutely NO cancellations. I understand that I am not purchasing medication and can choose most major local United States pharmacy to fill the prescription. Prescriptions can not be filled at internet, foreign or Canadian pharmacies.
Name, Phone #, Address of your Express Pharmacy

I have answered all the questions truthfully and I understand that by clicking submit I agree to all the terms and conditions including that my credit card will be charged the above stated amount for the consultation if approved.

Please CONFIRM YOUR SELECTION made above of receiving written prescription or your prescription called into local United States pharmacy

Option 1 : receive written prescription by mail in 7-15 days
Option 2 : have prescription called into a local United States pharmacy.


Click SUBMIT button for Physician Consultation for Aczone� Gel
You may submit Consultation Form over the Internet (secure server) by clicking the SUBMIT button. For any questions & fastest reply contact us by email at wellnessmd@medicalwellnesscenter.com

To contact Medical Wellness Center - Aczone� Gel Acne Prescription -with any questions, please Email us.

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