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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:
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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?:
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Are you currently using any topical
antibiotic prescriptions such as erythromycin or clindamycin , Delacin-T,
Cleocin-T?YES NO
If yes, please list:
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Are you currently using any skin
products containing sulfur, resorcinol or salicylic acid?YES NO
If yes, please list products using:
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Are you allergic to any creams
or lotions or skin care products?YES NO
If yes, please explain:
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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:
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Do you have very sensitive skin?YES NO
If yes, please how sensitive
your skin is:
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Is your skin frequently red or
irritated? YES NO
If yes, please explain:
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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
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Do you consider anything in your medical history to be relevant,
please give details.
If unsure, please ask your regular doctor
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Receive a written prescription
for Differin® with 6 refills valid and fill your prescription at most
any local United States pharmacy of your choice or have
your prescription for Differing with 6 refills called into your local
United States pharmacy of your choice at no extra charge.
Confirm your preference below.
If no preference indicated our physicians will make the determination based
on your history.
Differin®
Gel 0.1% Differin®
Cream 0.1%
AVAILABLE IN UNITED STATES
ONLY
Services not available
in Arkansas, Illinois, or Florida
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 to have
your prescription called into your local United States pharmacy. There
is no express service for refill consultations, only complementary call
in service.
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.
Check
only ONE of the two choices below!
Receive a written prescription
and fill your prescription at most any local U.S. pharmacy of your
choice, or have your prescription called into your local United
States pharmacy of your choice at no extra charge, or have your prescription
faxed to Murray Avenue Apothecary.
1.
Receive Written prescription:
Receive written prescription
by Priority Mail 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 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 and your credit card will be
billed the $75 consultation fee and regular S & P 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:
Choose to have your prescription
faxed to either Murray Avenue Apothecary and have the medication mailed
directly to you. If you select this choice you then must select
Murray Ave Apothecary.
If you selected to have your prescription
faxed to Murray Avenue Apothecary please select this choice below:
Murray
Avenue Apothecary: 412-421-4996
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,
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 & P)
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.
If you are
choosing to have your prescription called into your local pharmacy or faxed
to Murray Ave Apothecary, please select whether you want Regular service
or Express service.
Regular
Service: No extra charge 3 - 7 days : Prescription called
into your pharmacy or faxed to Murray Ave in 3-7 days- complementary.
Express
Service: $20 express processing fee - your prescription will be called
into your local pharmacy or faxed to Murray Ave 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, 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.
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 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
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.
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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.
For refill prescriptions
you have the option of:
1.
receiving a written prescription by mail (approximately 7- 15 days)
2.
have your prescription called into your local pharmacy or faxed Murray
Avenue Apothecary at NO EXTRA charge in 3 - 7 days - COMPLEMENTARY call
in service.
3.
or you can select EXPRESS 24 hour processing where your prescription will
be called into your local pharmacy or faxed Murray Avenue Apothecary 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
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% 45 gm Pump
Please CONFIRM YOUR
SELECTION made above of receiving written Rx or your Rx called into local
U.S. pharmacy or receive your medication from Murray Avenue Apothecary
:
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 # below
Option
3: Prescription faxed to Murray Avenue Apothecary
If you are
choosing (option 2, 3 or 4) to have your prescription called into your
local pharmacy or faxed to Murray Ave Apothecary, 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 or faxed to Murray Ave in 3-7 days- complementary.
Express
Service: $20 express processing fee - your prescription will be called
into your local pharmacy or faxed to Murray Ave in approximately 24 hours
or less.
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To contact Medical Wellness Center - Differin®
Acne Prescription -with any questions, please Email us.
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PHONE NUMBER:
(US ONLY) |
617-367-8887 |
Medical Wellness Center
Boston, MA
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