Latisse Eyelash Solution - REFILL Prescription

LATISSE EYELASH REFILL Medical Evaluation Form

Latisse Eyelash Prescription for thick, long, beautiful eyelashes

Welcome back. After your initial consultation and LATISSE ophthalmic solution approval each follow-up consultation, if approved, is only $75 and includes Latisse refill prescriptions good for 12 months. Hair growth is very slow and it takes up to 16 weeks to get the full benefits of enhanced length, thickness, fullness of your eyelashes. Hypotrichosis or inadequate eye lashes is most often a life-long condition and you need to continue to use Latisse to maintain the benefits of enhanced length and prominence of your eyelashes. Please accurately and completely provide the following information in order for a physician to review your record. You must include your Medical Wellness Center Membership Number which was assigned upon approval into the program. (If you don't have this available, you can Email us for your membership number.)

NOT AVAILABLE IN ILLINOIS AND ARKANSAS AND FLORIDA

Please fill in all fields and respond to all questions honestly and completely so that a physician can review your consultation and prescribe Latisse if approved. Do NOT combine Latisse with other prescription eye drops for glaucoma or Intraoccular Pressure problems Do not use if pregnant or nursing . If the consulting physician determines that Latisse Refills are not appropriate for you, there is NO charge for this consultation.

Click here to read the stated conditions before filling out the medical consultation form: I have read the previous Latisse 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: Medical Wellness Center Membership Number: 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:

Describe your response to Latisse treatment and detail the progress. Detail how long before you started to notice changes etc.

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:

Do you take any prescription medication or use any prescription eye drops?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:

Have you had a physical exam in the last two years?YES NO


Are allergic to Latisse, bimatoprost or any of the ingredients in Latisse? YES NO
Have you ever been diagnosed in the past with increased Intraoccular Pressure - Glaucoma? YES NO
Are you currently using any medication to treat glaucoma? YES NO If yes, please list all prescription eye medications for glaucoma used:
Are you currently using any prescription eye drops to treat IOP - Intraocccular Eye Pressure Conditions?YESNO If yes, please list all prescription eye medications used:
Are you currently pregnant or nursing? YES NO
Are you currently LUMIGAN, Xalatan or Travatan or other Prostaglandin analogs for glaucoma eye drops in your eye ( Bimatoprost ophthalmic solution )YES NO
Are you currently being treated for cancer?YES NO If yes, please explain:

Do you smoke?YES NO

How much alcoholic beverages do you drink?
None Occasionally Moderately Heavily

CURRENT MEDICAL CONDITIONS & PAST MEDICAL HISTORY
Do you have or have you ever had any of the following conditions?
Glaucoma	Increased Intraoccular Pressure	Liver Disease
Jaundice	Kidney Disease	Eye Pressure Problems
Coronary Artery Disease	Heart Attack	Heart disease
High Blood Pressure	Stroke	Diabetes
Thyroid disease	Depression
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

**PERSONAL and PAYMENT INFORMATION**
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: (Physical Address Necessary We do NOT process any orders to PO BOX#'s)
CITY:
STATE:	ZIP CODE
COUNTRY:
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 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.)
Name, complete Phone # including area code, Address of your Pharmacy:
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 that youi 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, 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 a 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 Latisse is not to be used by anyone under the age of 18.
I understand that Latisse is NOT to be used by pregnant or nursing woman.
I am aware that I need to inform my doctor that I am using Latisse when going to an ophthalmologist and /or having my intraoccular pressure measured.
I do not have any of the contraindications to therapy.
I am not currently using any prescription eye drop medication for glaucoma or IOP -Intraoccular Pressure Problems
I understand that I must NOT combine Latisse with LUMIGAN, Xalatan or Travatan or other Prostaglandin analogs for glaucoma eye drops
I understand that my credit card will be billed $75.00 (plus S&P $9.50 or $20) for the medical consultation if approved, if not approved there is no charge for the consultation. I understand that by submitting this form it's an "electronic signature" of a binding agreement that I agree to pay the $75.00 consultation fee plus S & P 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 or take the medication or I am advised not to take this medication by another physician. I understand that whether I choose to fill the prescription or not or whether I change my mind and decide not to take the medication, there are absolutely NO refunds for the online consultation fee. It is YOUR responsibility to make sure the pharmacy you list can provide you with the medication. Also, if a pharmacy refuses to fill a valid prescription issued by Medical Wellness Center due to do failure to verify your billing/shipping// & or Credit card information that you provided to the pharmacy or failure of your payment authorization to them we do NOT refund the consultation fee.

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
Name, complete Phone # including area code
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.


Click SUBMIT button for Physician Consultation for Latisse Eyelash Solution REFILLS
You may submit Consultation Form over the Internet (secure server) by clicking the SUBMIT button. For any questions email at wellnessmd@medicalwellnesscenter.com

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

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

Medical Wellness Center