Topical Enhancement Cream + Sidenafil for Sexual Responsiveness Enhancement and Penile Clitoral Stimulation- Consultation

Sexual Enhancement Penile / Clitoral Stimulation Cream:
Medical Evaluation Form

OMG Stimulation Cream + Sildenafil prescription

Please fill in all fields and respond to all questions honestly and completely so that a physician can review your consultation and prescribe Topical Stimulation Cream + Sildenafil if approved. If approved your prescription will be faxed to a compounding pharmacy with 6 additional refills. You will receive a confirmation email when approved. If the consulting physician determines that Topical Sexual Enhancement Cream + Sidenafil is not appropriate for you, there is NO charge for this consultation.

AVAILABLE IN UNITED STATES ONLY

NOT AVAILABLE IN ILLINOIS AND ARKANSAS AND FLORIDA

Click here to read the stated conditions before filling out the medical consultation form: I have read the previous Topical Sexual Enhancement Cream + Sidenafil 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: Female Male 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.

Do you currently take oral Nitrate medication for heart disease?YESNO

Do you currently take any of the following Drugs: Hytrin (terazosin HCL), Flomax(tamsulosin), Cardura(Doxazosin) Minipress(prazosin), Uroxatral(alfuzosin), Jalyn(duateride & Tamsulosin) or Rapaflo (silodosin)?YESNO

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

Do you have or have you been diagnosed with genital herpes?YESNO

Do you currently have or are you being treated for genital herpesYESNO

Do you currently have any genital blisters, lesions or irritations? YES NO

Are you allergic to L-Arginine, Niacinamide, Menthol or Sildenafil?YES NO

Are you on nitrates for heart disease? YES NO

If a woman are you currently pregnant, trying to get pregnant or breast feeding?YESNO

If male, is your partner currently pregnant, trying to get pregnant or breast feeding?YESNO

Do you any health issues that would affect your ability to be healthy enough to have sex?

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?
Genital blisters	gallbladder disease	Liver Disease
Genital herpes	Leukemia or Multiple Myeloma	Hepatitis
Retinitis Pigmentosa	Kidney Disease	Severe Vision Loss
Erectile Dysfunction	Enlarged Prostate	Sickle Cell Anemia
Coronary Artery Disease	Heart Attack	Heart disease
High Blood Pressure	Stroke	Diabetes
Thyroid disease	Depression	Endocrine Disorders

Are you currently on Chemotherapy treatment for cancer?YES NO

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?
Diabetes	Liver Disease	Stroke
High blood pressure	Heart disease	Arteriosclerosis
Kidney Disease	Gallbladder disease	Cancer
Prostate Cancer	Benign Prostate Enlargement	Retinitis Pigmentosa
Are there any other diseases than run in your family?

**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
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
EXPIRATION DATE(MM/YY):

You can choose REGULAR or EXPRESS SERVICE: Regular service - $49.95 consultation fee plus $10.30 processing fee to Medical Wellness Center for the online doctor visit. Consultation reviewed in 3 - 7 days and faxed to Murray Avenue Apothecary. Express Service - $49.95 consultation fee plus $20 express fee. Consultation reviewed and your prescription faxed to Murray Avenue Apothecary within approximately 24 hours. Please check below whether you want Regular service or Express service Regular service- consult reviewed and faxed to Murray Avenue Apothecary within 3 - 7 days Express service- consult reviewed and faxed to Murray Avenue Apothecary within approximately 24 hours 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

By submitting this consultation form, I certify:

I am a male 18 years of age or older.
I have read and agree to Waiver of Liability.
I understand the possible side effects for this medication.
If female, understand that I am not pregnant, trying to get pregnant or nursing; and if male I understand that my partner must not be pregnant, trying to get pregnant or breast feeding.
I understand must Topical Stimulation Cream if have genital irritation, blisters, or genital herpes.
I do not have any of the contraindications to therapy.
I understand that my credit card will be billed $49.95 (plus S&P $10.35 or $20 for express service) 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 $49.95 consultation fee plus S & P if approved. I understand that there are no refunds for any circumstances even if I later change my mind and decide not to fill the prescription or purchase the medication from the compounding pharmacy or I am advised not to take this medication by another physician. If approved I understand I am not purchasing medication from Medical Wellness Center but rather the online consultation service. I purchase the medication from the pharmacy where the prescription is forwarded. I understand that whether I choose to fill the prescription or not or whether I change my mind and decide not to use the medication, there are absolutely NO refunds for the online consultation fee. Also, if the 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.

AVAILABLE IN UNITED STATES ONLY
****If you have any concerns of whether the pharmacy can ship to your location,
you must contact the pharmacy first to confirm that they can ship to your address.
There are NO refunds for consultations if the pharmacy can not ship to your location.

Your prescription for your compounded topical Topical Stimulation Cream preparation will be forwarded to Murray Avenue Apothecary. Murray Avenue Apothecary is a compounding pharmacy and they will contact you directly by email for your payment and shipping information. (www.maapgh.com)

Medical Wellness Center is a physician consulting service and does not sell or dispense medication. Our preferred compounding provider is Murray Avenue Apothecary. For pricing you need to contact Murray Avenue Apothecary either at susan@maapgh.com or tonya@maapgh.com.

Confirm your choice of REGULAR or EXPRESS SERVICE:

Regular service - $49.95 consultation fee plus $10.30 processing fee to Medical Wellness Center for the online doctor visit. Consultation reviewed in 3 - 7 days and faxed to Murray Avenue Apothecary.

Express Service - $49.95 consultation fee plus $20 express fee. Consultation reviewed and your prescription faxed to Murray Avenue Apothecary within approximately 24 hours.

Please check below whether you want Regular service or Express service

Regular service- consult reviewed and faxed to Murray Avenue Apothecary within 3 - 7 days
Express service- consult reviewed and faxed to Murray Avenue Apothecary within approximately 24 hours

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.

**Medical Wellness Center is not affiliated or associated with Murray Avenue Apothecary. Murray Avenue Apothecary is a privately owned pharmacy and is completely independent of Medical Wellness Center. Medical Wellness Center provides customized treatments based on almost 20 years experience treating male pattern hair loss, and they forward all compounded hair loss prescriptions exclusively to Murray Avenue Apothecary because of the integrity and reliability of this United States based, privately owned, local pharmacy; the experience of Susan Merenstein, the compounding pharmacist; and that this pharmacy only uses FDA approved ingredients.


Click SUBMIT button for Physician Consultation for topical Topical Stimulation Cream
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 , please Email us.

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