ClarinexREFILLHistoryConsultationForm

CLARINEX REFILL Medical Consultation:

Welcome back. After your initial consultation and Clarinex prescription approval, each follow-up consultation, if approved, is only $75.00 and includes Clarinex refill prescriptions for one year.

Please fill in all fields and respond to all questions honestly and completely so that a physician can review your consultation and record. You must include your Medical Wellness Center membership number which was assigned to you upon your initial approval into the program. (If you do not have this available, you can Email us for your membership number.)

Available in the United States Only.
Not available in Arkansas, Illinois or Florida

Please be sure to read Clarinex contraindications, warnings, and 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.
I have read the previous Clarinex 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 LiabilityYES NO

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

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

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)

Please list all current Medical Conditions:

Please list all current Prescription Medications:

Please list all over-the-counter drugs you take regularly and why:

Please list any known Allergies to Medicines:

Please list all past surgical history and dates:


If female, are pregnant or presently breast feeding? YES NO
Do you renal (kidney) or hepatic (liver) impairment or disease or are you on dialysis? YES NO

Have you ever had any type of transplant such as kidney or liver? YES NO
Do you currently use medication to treat your allergy symptoms? YES NO *If yes, please check any of the following prescription antihistamines you are CURRENTLY* taking: None Any Claritin product Any Claritin-D family product Any Allegra product Any Allegra D product Any Zyrtec product other Please check any of the following prescription Nasal Spray you are CURRENTLY taking: None FLONASE NASONEX other Please check any of the following over-the-counter allergy medications you are CURRENTLY taking:** None Allergy tablets/ syrup Cold tablets/ syrup (decongestant) Nasal Spray other If I am currently taking one of the above prescription antihistamines or over-the-counter antihistamines, I understand that Clarinex can not be taken along with any other antihistamine. and I understand that I have to discontinue use of any other prescription or nonprescription antihistamine and replace it with CLARINEX 5 mg tablet once a day. YES NO
Have you had a complete physical exam within the last 2 years? Yes NO
Do you smoke?YES NO
How much alcoholic beverages do you drink? None Occasionally Moderately Heavily

ALLERGY HISTORY

Do you suffer from year-round or seasonal allergies Yes No

Have you been diagnosed by a physician to suffer from allergies Yes No

Which of the following do you experience (check all that apply)
Seasonal Allergies Year Round Allergies

Check below all the months during which you experience allergy symptoms
All months January February March April	May June July August	September October November December

Check below all the allergy-related symptoms you experience
Runny nose Stuffy nose itchy nose mouth breathing	Itchy/watery eyes Congestion scratchy throat Post nasal drip	puffy eyes Sneezing itchy throat hives

Which of the following are you allergic to (check all that applies
Pollens(trees, grass, weeds)	Molds
Dust	Foods
Pet Dander	Chemicals
other

Have you been treated with prescription allergy medication in the last 12 months?Yes No
If yes, please list prescription allergy medications you have taken.:

Please check below the severity of your allergy symptoms?
Mild Moderate Severe

Please list types of treatment for allergies you have received in the past:

At what age did you first experience allergies?

Please describe your allergy symptoms frequency, duration, severity, precipitating allergens - pollens, pet dander etc?

CURRENT MEDICAL CONDITIONS & PAST MEDICAL HISTORY
Do you have or have you ever had any of the following conditions?
Kidney Disease	Renal failure	Kidney dialysis
Liver disease	HIV Positive	Advanced HIV
Allergies	Asthma	Eczema
Organ Transplant	Kidney Transplant	Liver Transplant
Hives	Seizures	Anxiety
Coronary Artery Disease	Heart Attack	Heart disease
High Blood Pressure	Stroke	Diabetes
Thyroid disease	Depression	Endocrine Disorders

Are you currently taking steroids? YES NO
Are you currently being treated for cancer? YES NO If yes, please explain:
Have you had surgery in the last 3 months? YES NO If yes, please explain:

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?
Allergies	Asthma	Eczema
Hives	Liver Disease	Diabetes
High blood pressure	Heart disease	Arteriosclerosis
Kidney Disease	Gallbladder disease	Cancer
Are there any other diseases than run in your family?

**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.
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 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 Amazon.com or an internet version of a local pharmacy such as CVS.com etc.)

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

If you are choosing to have your prescription called into your local pharmacy, please select 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.
EXPRESS SERVICE: $20 express processing fee instead of the $9.50 regular processing fee- your prescription will be called into your local pharmac in approximately 24 hours.

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 and adverse effect.
I understand that Clarinex will not to be prescribed to anyone under the age of 18.
I understand that that pregnant and nursing mothers should not use Clarinex because there are not sufficient studies and I am not pregnant or nursing.
I am aware that in order to be eligible to receive a Rx, I must have been positively diagnosed to suffer from allergies, and I need to inform my doctor that I am using Clarinex
I do not have any of the contraindications to therapy.
I do not have a current prescription for Clarinex from another physician, and I will not combine this antihistamine treatment, Clarinex, with any other prescription or over-the-counter antihistamine allergy medication..
I understand that my credit card will be billed $75.00 and $9.50 S & H for the 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 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.
Please check here if you are requesting your prescription to be called into your local United States pharmacy. If approved your prescription will be called into a local United States pharmacy of your choice at no extra charge
I certify that 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 for the consultation if approved. I understand that if approved, I will receive a written prescription for Clarinex with 6 additional refills that can be filled at most any local United States Pharmacy of my choice. Once submitting this consultation I can not receive a credit for the consultation service if I for any reason change my mind and no longer choose to use the medication or choose not to fill the prescription

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

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

If you are choosing (options 2, 3 or 4) to have your prescription called into your local pharmacy, please confirm your selection of whether you want regular service or Express service.

REGULAR SERVICE: No extra charge 3 - 7 days : Prescription called into your pharmacy- complementary.
EXPRESS SERVICE: $20 express processing fee - your prescription will be called into your local pharmacy in approximately 24 hours or less.


Click SUBMIT button for Physician Consultation for Clarinex
You may submit Consultation Form over the Internet by clicking the SUBMIT button. For any questions & fastest reply contact us by email at Wellnessmd@yahoo.com

To contact Medical Wellness Center -with any questions, please Email us.

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