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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
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 or RXUSA Pharmacy (RXUSA
pharmacy can only ship to CT, DE, HI, IN, KS, ME, MO, NJ, NM, NV, NY, OH,
OK, RI, SC, UT, VT, WA, WI and WY) 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 or RXUSA 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 or RXUSA:
Choose to have your prescription
faxed to either Murray Avenue Apothecary or RXUSA pharmacy and have the
medication mailed directly to you. If you select this choice
you then must select below whether you want Murray Ave Apothecary or RXUSA.
(RXUSA
pharmacy can only ship to CT, DE, HI, IN, KS, ME, MO, NJ, NM, NV, NY, OH,
OK, RI, SC, UT, VT, WA, WI and WY)
Only if you selected to have your
prescription faxed to and filled by Murray Avenue Apothecary or RXUSA pharmacy
please select your 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: RXUSA
Pharmacy - 516-467-2500 or 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)
RXUSA
PHARMACY:
1 800-764-3648 or 1 800-798-7248 or 516-467-2500
(RXUSA
pharmacy can only ship to CT, DE, HI, IN, KS, ME, MO, NJ, NM, NV, NY, OH,
OK, RI, SC, UT, VT, WA, WI and WY)
Please
check here authorizing RXUSA Pharmacy 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 ($75.00 + 9.50 S &
H or $20 if selecting express service), you will be billed separately by
RXUSA pharmacy for the medication. 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 or RXUSA, 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 or RXUSA
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 or RXUSA in approximately 24 hours.
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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 $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 certify that I
have answered all the questions truthfully.
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 or RXUSA pharmacy:
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
Option
4 : Prescription faxed to RXUSA pharmacy
CONFIRM
you selection of Regular Service or Express Service.
Regular
Service: No extra charge 3 - 7 days : Prescription called
into your pharmacy or faxed to Murray Ave or RXUSA 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 or RXUSA 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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