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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 tacrolimus, the active ingredient in Protopic Ointment or any inactive
component: mineral oil, paraffin, propylene carbonate, white petrolatum
and white wax? 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
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. 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. 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.
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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 and adverse effect which are burning,
tingling, itching at site of application, and rarely increased risk of
chicken pox, shingles, herpes simplex virus infection or eczema herpeticum..
I
understand that Protopic Ointment 0.1% is not to be used by anyone under
the age of 18, anyone with infected, oozing eczema skin lesions or anyone
with Netherton's Syndrome.
I
understand that pregnant, attempting to become pregnant and nursing mothers
should NOT use Protopic 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 Protopic.
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 Protopic Ointment with any other topical skin
products or topical prescriptions, except moisturizers and sunblock.
I do not have
a current prescription for Protopic from another physician.
I
understand that my credit card will be billed $49.95 and $10.35 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 $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 I click SUBMIT button
I can not cancel this consultation request for any reason.
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 pharmacy of your
choice within approximately 24 hours. If you checked yes and you
are approved you will be billed a $20 express S & H processing
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, 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:
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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To
contact Medical Wellness Center -with any questions, please Email us. |
PHONE NUMBER:
(US ONLY) |
617-367-8887 |
Medical Wellness Center
Boston, MA
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