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 |
|
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 faxed to Murray Avenue Apothecary or RXUSA(RXUSA
pharmacy can only ship to CT, DE, HI, IN, KS, ME, MO, NJ, NM, NV, NY, OH,
OK, RI, SC, UT, VT, WA, WI and WY), 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 or faxed to
Murray Avenue Apothecary or RXUSA Pharmacy(RXUSA
pharmacy can only ship to CT, DE, HI, IN, KS, ME, MO, NJ, NM, NV, NY, OH,
OK, RI, SC, UT, VT, WA, WI and WY)atNO 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 or faxed to Murray
Avenue Apothecary or RXUSA 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.)
3.
Prescription faxed to Murray Avenue Apothecary or RXUSA:
Choose to have your prescription
faxed to either Murray Avenue Apothecary or RXUSA pharmacy and have the
medication mailed directly to you. If you select this choice
you then must select below whether you want Murray Ave Apothecary or RXUSA
(RXUSA
pharmacy can only ship to CT, DE, HI, IN, KS, ME, MO, NJ, NM, NV, NY, OH,
OK, RI, SC, UT, VT, WA, WI and WY).
Only if you selected to have your
prescription faxed to and filled by Murray Avenue Apothecary or RXUSA pharmacy
please select your choice below: (It
is imperative that you check first with the pharmacies on pricing of the
medication. Medical Wellness Center only bills you for the consultation
fee and the pharmacy you select will bill you directly for the medication
itself. If you have any questions in regards to shipping status and tracking
information you need to contact the pharmacy directly: RXUSA
Pharmacy - 516-467-2500 or Murray Avenue Apothecary 412-421-4996.)
Murray
Avenue Apothecary: 412-421-4996
Please
check here authorizing Murray Avenue Apothecary to fill your prescription,
and 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 + 9.50 S & H or $20 if selecting express service)
RXUSA
PHARMACY :
1 800-764-3648 or 1 800-798-7248 or 516-467-2500
(RXUSA
pharmacy can only ship to CT, DE, HI, IN, KS, ME, MO, NJ, NM, NV, NY, OH,
OK, RI, SC, UT, VT, WA, WI and WY)
Please
check here authorizing RXUSA Pharmacy to fill your prescription,
and your prescription will be faxed to RXUSA and you then need to
contact the pharmacy - 1 800-764-3648 or 800-798-7248 and make sure you
register all necessary information for payment and shipping with them to
expedite receiving your prescription. Medical
Wellness Center will only bill you for the online consultation fee ($75.00
+ 9.50 S & H or $20 if selecting express service), you will be billed
separately by RXUSA pharmacy for the medication. You need to call the pharmacy
directly for pricing
Please CONFIRM YOUR
SELECTION made above of receiving written prescription or your prescription
called into a local U.S. pharmacy or receive your medication from Murray
Avenue Apothecary or RXUSA 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 # below
Option
3: Prescription faxed to Murray Avenue Apothecary
Option
4: Prescription faxed to RXUSA pharmacy (RXUSA
pharmacy can only ship to CT, DE, HI, IN, KS, ME, MO, NJ, NM, NV, NY, OH,
OK, RI, SC, UT, VT, WA, WI and WY)
If you are choosing
(Option 2, 3, or 4) to have your prescription called into your local pharmacy
or faxed to Murray Ave Apothecary or RXUSA, 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 or faxed to Murray Ave or RXUSA 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 Murray Ave or RXUSA in approximately 24
hours or less.
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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.
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.
Option
3 : have prescription faxed to either Murray Avenue Apothecary or RXUSA
pharmacy.
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