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Have you previously been diagnosed
in the past to suffer from atopic dermatitis or eczemaYES
NO |
Are you currently Pregnant, trying
to become pregnant or Breast-feeding? YES NO |
Are you hypersensitive or allergic
to pimecrolimus, the active ingredient in Elidel cream or any inactive
components:benzyl alcohol, cetyl alcohol, citric acid, mono- and di-glycerides,
oleyl alcohol, propylene glycol, sodium cetostearyl sulphate, sodium hydroxide,
stearyl alcohol, triglycerides and water? YES NO |
Do you suffer from Netherton's
Syndrome? YES NO |
Do you have acute infectious
mononucleosis? YES NO |
Do you CURRENTLY have any INFECTED,
weeping,
oozy eczema lesions? YES NO |
Have you ever had any type of
transplant such as kidney, lung, heart or bone marrow?YES NO |
Do you have AIDS or a positive
HIV test or have you recently been exposed to AIDS?YES NO |
Are you allergic to any creams
or lotions or skin care products? YES NO
If yes, please explain:
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Are you currently using any topical
PRESCRIPTION medications on your body? YES NO
If yes, please explain and detail
the areas of use and if it is on the area of the eczema lesions or a different
area:
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Are you currently
being treated for cancer?YES NO
If yes, please explain:
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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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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 faxed to
Murray Avenue Apothecary 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 or faxed to 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
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:
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 below whether you want Murray Ave Apothecary.
Only if you selected to have your
prescription faxed to and filled by Murray Avenue Apothecary please select
this 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: \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. 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. You need to call the pharmacy directly
for pricing
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, regular processing fee of $9.50:
Prescription called into your pharmacy or faxed to Murray Ave 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
pharmacy or faxed to Murray Ave 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 which are burning
and a sensation of warmth at site of application, and rarely increased
risk of chicken pox, shingles, herpes simplex virus infection or eczema
herpeticum. Also side effects may include cold/stuffy nose, influenza,
sore throat, fever, viral infection and cough.
I
understand that Elidel Cream is not to be used by anyone with infected,
oozing eczema skin lesions or anyone with Netherton's Syndrome.
I
understand that Elidel Cream is not to be used by anyone who is HIV positive,
has active mononucleosis or is immunocompromised
I
understand that pregnant, attempting to become pregnant and nursing mothers
should NOT use Elidel Ointment.
I
am aware that in order to be eligible to receive a Rx, I must have been
positively diagnosed with eczema/ atopic dermatitis in the past,
and I need to inform my doctor that I am using Elidel cream.
I
do not have any of the contraindications to therapy and I have read and
understand the contraindications and possible side effects. I understand
that I must NOT use Elidel cream with any other topical skin products
or topical prescriptions, except moisturizers and sunblock.
I do not have
a current prescription for Elidel cream from another physician
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 under any circumstances), if not approved there is NO charge.
I understand that by submitting this form I agree to pay the $75.00 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 I click SUBMIT button
I can not cancel this consultation request for any reason.
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 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 -with any questions, please Email us. |
PHONE NUMBER:
(US ONLY) |
617-367-8887 |
ADDRESS: |
Medical Wellness Center |
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Marlborough, MA 01752 |
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