Differin Doctor consultation

Differin® Medical Consultation Form

Differin Online Prescriptions for acne treatment

Please fill in all fields and respond to all questions honestly and completely so that a physician can review your consultation and prescribe Differin® if approved. If the consulting physician determines that Differin® is not appropriate for you, there is NO charge for this consultation. Available in the United States Only.
Not available in Illinois and Arkansas and Florida

Differin® is available in several different formulations. Select your choice below:

Differin Gel 0.3% 45gm tube
Differin gel 0.3% Pump 45gm

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 Differin®. Please be sure to read Differin® 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 Differin® 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:YES NO

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

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

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
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 comedones - 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	Grade IV

Differin® (adapalene) comes in several formulations. We prescribe both Differin® Gel and the Differin® cream. For those with very sensitive skin, you may want to use Differin® cream. Please check below whether you want a Differin® Gel or Differin® Cream. If you do not indicate a preference, our physicians will make the determination based on your history.

Differin® Gel 0.1% Differin® Cream 0.1%

**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

You can choose to fill your prescription and your local United States pharmacy.
In addition you can choose either Regular or 24 hour Express Service:

You can choose to receive a written prescription and fill your prescription at most any local United States pharmacy of your choice or EXPRESS service and have your prescription called into the local United States pharmacy of your choice.

Our prescriptions can only be filled at a local United States pharmacy of your choice, they can not be filled at internet or foreign or Canadian or internet versions of pharmacies. If you would prefer to receive your medication by mail you can choose to have your prescription faxed to one of two approved local United States pharmacies that will mail your medication directly to you. The pharmacy will contact you and fill the prescription and mail the medication directly to you. (Medical Wellness Center has no financial ties to either of these pharmacies. They were chosen for their outstanding customer service, excellent compounding expertise, and reliability. They only dispense 100% FDA approved manufactured medications.)
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.

1. First choose whether you want to fill you prescription at your local U.S. pharmacy or at Murray Avenue Apothecary. Choose only ONE of these two choices.

Prescription filled at your local United States pharmacy:
Choose to fill prescription at your local pharmacy: Please check here if you are choosing to fill your prescription at your local United States pharmacy. If you want to purchase your prescription from your local pharmacy, you then can select whether you want Regular service and wait 7-15 days to receive your written prescription by mail or whether you want Express service and your prescription is called into your local pharmacy in approximately 24 hours.

Murray Avenue Apothecary: 412-421-4996
Murray Avenue Apothecary is a specialized compounding pharmacy. This pharmacy has excellent pricing, especially for medications that are not covered by insurance or for those who do not have insurance. Please check FIRST with the pharmacy in regards to pricing of the medication. Only if you are choosing to fill your prescription online and have Murray Avenue Apothecary ship the medication to you check below:
Authorized Murray Avenue Apothecary to fill prescription : Please check here authorizing Murray Avenue Apothecary to fill your prescription. 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.

If you have any questions in regards to shipping status and tracking information you need to contact the pharmacy directly: Murray Avenue Apothecary 412-421-4996.

2. Next after making this selection then choose whether you want regular service (7-15 days) or Express 24 hour service.

REGULAR SERVICE: Consult reviewed within approximately 3-7 business days and your will receive a written prescription by mail in approximately 7- 15 days which you can take to most any local United States pharmacy of your choice and fill or have your prescription faxed to Murray Ave Apothecary in 3-7 days. Processing fee $10.35
EXPRESS SERVICE: Consult reviewed and prescription within approximately 24 hours called into most any local United States pharmacy of your choice or faxed to Murray Avenue Apothecary pharmacy. Express processing fee $20.
Please check here if you are requesting our EXPRESS review and processing of your medical evaluation. If approved your prescription will be called into your LOCAL United States pharmacy of your choice within 24 hours. If you checked yes and you are approved you will be billed a $20 express processing fee.
IF YOU ARE REQUESTING EXPRESS SERVICE CALLED INTO A PHARMACY MAKE SURE YOU ENTER THE NAME, ADDRESS AND PHONE NUMBER OF YOUR LOCAL UNITED STATES PHARMACY BELOW
If you are requesting express service, please enter complete phone# including area code, name and address of pharmacy where you choose to fill your prescription. If you are selecting Murray Avenue Apothecary just write in your choice, you do not need to include phone number. 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, Phone # Address of EXPRESS Pharmacy.

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, stinging, or a feeling of warmth which may go away during course of treatment. If you experience Blistering, Crusting, Swelling, Excessive redness or peeling of your skin CHECK WITH YOUR DOCTOR AS SOON AS POSSIBLE!
I understand that Differin® is for TOPICAL use only. Avoid eyes, angles of the nose, mucous membranes.
I understand that pregnant and nursing mothers should NOT use Differin®, and I agree not to use Differin® if I am trying to get pregnant.
I am aware that Differin® increases sensitivity to sun and I agree to limit exposure to the sun, use SUNBLOCK daily and I agree NOT to use Tanning Beds or sunlamps of any sort. Differin® is NEVER to be used on sunburned skin
I understand that Differin® must be STOPPED for 3 - 4 weeks prior to any irritating skin procedures such as Electrolysis, Hair Depilatories, Waxes, Peels or laser or plastic surgery.
I understand that I am NOT to use Benzoyl Peroxide on my face at the same time I using Differin®. 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 Differin®..
I understand that I am NOT to use any topical products containing sulfur, resorcinol or salicylic acid while using Differin®.
I understand that I am NOT to use any abrasive soaps, astringents, alcohol-containing skin products on my skin while using Differin®.
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 Retin A or Renova..
I do not have a current prescription for Differin® from another physician.
I understand that my credit card will be billed $49.95 and $10.35 S & H processing fees for the medical consultation if approved (no refunds for this consultation service under any circumstances), if not approved there is NO charge. I understand that by submitting this form I agree to pay the $49.95 consultation and S& H fees if approved and understand that there are no refunds for any circumstances even if I later change my mind and decide not to fill the prescription I receive or decide not to take the medication for any reason. I understand that once submitted, my request for a physician consultation can not be canceled.
Please check here if you are requesting our EXPRESS (available in United States only) review and processing of your medical evaluation. If approved your prescription will be called into a local pharmacy of your choice within 24 hours. We do not call in prescriptions to any internet pharmacies such as Drugstore.com etc.

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 of the Differin strength and whether you prefer a gel or cream:

Select below your choice:
Differin Gel 0.3% 45gm tube
Differin gel 0.3% Pump 45gm

Please CONFIRM YOUR SELECTION made above of receiving written Rx, Express Service called into local U.S. pharmacy:

Option 1: Regular Service - receive written prescription by mail in 7-15 days
Option 2: EXPRESS Service - have prescription called into a local U.S. pharmacy within approximately 24 hours
If you selected Express service, confirm the name and phone number of your Local United States Pharmacy below:
Name, Phone # Address of EXPRESS Pharmacy
Option 3: Murray Avenue Apothecary ships you the medication to your home - Regular Service: consult reviewed and faxed to Murray Avenue Apothecary in 3-7 days
Option 4: Murray Avenue Apothecary ships you the medication to your home - Express Service: consult reviewed and faxed to Murray Avenue Apothecary in approximately 24 hours
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Click SUBMIT button for Physician Consultation for DIFFERIN®
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 - Differin® Acne Prescription -with any questions, please Email us.

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