Soolantra Cream consultation

Soolantra® Cream Medical Consultation Form

Soolantra Cream Online Prescriptions for Rosacea treatment - FDA approved

Please fill in all fields and respond to all questions honestly and completely so that a physician can review your consultation and prescribe Soolantra® cream if approved. If the consulting physician determines that Soolantra® cream is not appropriate for you, there is NO charge for this consultation. Available in the United States Only.
Not available in Illinois and Arkansas and Florida In order for Medical Wellness Center's Physicians to provide you with the best care you need to reply honesty to all questions and you need to understand any and all risks and side effects associated with Soolantra® cream. Please be sure to read Soolantra®cream CONTRAINDICATIONS, WARNINGS and SIDE-EFFECTS and confirm that you do NOT have any contraindications, understand the warnings and agree to the Waiver of Liability before filling out this consultation. Failure to answer truthfully and completely could result in serious consequences !
Click here to read all the above stated conditions before filling out the medical consultation form: I have read the previous Soolantra® cream 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: FemaleMale 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.

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:

Are you currently Pregnant or Breast-feeding? YES NO
Are you currently trying to become pregnant? YES NO
Are you currently using any topical PRESCRIPTION medications on your face? YES NO If yes, please explain:
Are you currently being treated with any prescription medications for rosacea?YES NO If yes, please detail what medication you are using, how long and why you are using it?:
Are you currently using any topical antibiotic prescriptions such as erythromycin or clindamycin , Delacin-T, Cleocin-T?YES NO If yes, please list:

Are you allergic to any creams or lotions or skin care products?YES NO If yes, please explain:
Do you have any pre-existing or chronic skin disorders in addition to rosacea such as but not limited to eczema, seborrheic dermatitis or psoriasis? YES NO If yes, please describe your condition, how long, severity and location:
Do you have very sensitive skin?YES NO If yes, please how sensitive your skin is:
Is your skin frequently red or irritated? YES NO If yes, please explain:
Are you extremely sensitive to the sun? YES NO
Please list any plastic surgery, laser or medical peels or cosmetic procedure you have had in your lifetime on your face and when these procedures were done:

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

Are you currently taking steroids? YES NO

Do you smoke?YES NO

Do you consume more than 2 servings of alcohol per day?
YES NO

Have you had surgery in the last 3 months?
YES NO
If yes, please explain:

Are you currently being treated for cancer? YES NO
If yes, please explain:

CURRENT MEDICAL CONDITIONS ? PAST MEDICAL HISTORY
Do you have or have you ever had any of the following conditions?
Kidney Disease	Liver disease	Sebborheic Dermatitis
Eczema	Skin Disease	Psoriasis
Skin Cancer	Mental Illness	Depression
Organ Transplant	Seizures	Anxiety
Coronary Artery Disease	Heart Attack	Heart disease
High Blood Pressure	Stroke	Diabetes
Thyroid Disease	Adrenal Disease	Endocrine Disorders

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?
Acne	Liver Disease	Stroke
Eczema	Skin Diseases	Skin Cancer
High blood pressure	Heart disease	Diabetes
Kidney Disease	Gallbladder disease	Cancer
Are there any other diseases than run in your family?
Do any of your family members suffer skin diseases? If yes describe the relation and the severity of the skin condition:

**Rosacea Skin History**
Have you diagnosed with Rosacea by a physician in the past?Yes No
At what age did you first experience rosacea?
Have you been treated for rosacea in the past?Yes No If yes, please list types of treatment for rosacea you've received in the past:
Do you have Ocular Rosacea?Yes No
If Yes, are you receiving physician monitoring for your Ocular Rosacea?Yes No If yes, please describe how Rosacea affects your eyes and medical treatment:
Are you currently on any treatment regimen for you Rosacea -both over the counter and prescription products?Yes No If yes, please list types of treatment for rosacea you are currently receiving:
Please describe your rosacea condition. Describe areas of the body affected and severity. How long you've suffered with rosacea? Are the rosacea flare-ups decreasing or increasing in frequency and severity?.
Please describe what triggers your rosacea flare-ups?.
Please describe what your daily skin care regimen is.
Do you have a family history of rosacea? YES NO If yes, please explain:

**PERSONAL and PAYMENT INFORMATION**
**Available in the United States Only**
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:
CITY:
STATE:	ZIP CODE
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

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.
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.

Choose whether you want regular service (7-15 days) or Express 24 hour service.

REGULAR SERVICE: Consult reviewed within approximately 3-5 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. 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. 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 Amazon.com or an internet version of a local pharmacy such as CVS.com etc.
Name, Phone # Address of EXPRESS Pharmacy.

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 have read and understand the side effects of this medication.
I understand that pregnant and nursing mothers should NOT use Soolantra® cream, and I agree not to use Soolantra® cream if I am trying to get pregnant.
I am not pregnant.
I am not currently breast feeding. I am aware that Soolantra® cream (ivermectin) gets into breast milk.
I do not have any of the contraindications to therapy.
I do not have a current prescription for Soolantra® cream or ivermectin from another physician.
I understand that my credit card will be billed $49.95 and $10.35 processing fees 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 processing 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 submitted, my request for a physician consultation can not be canceled.
Please check here indicating that you understand that you are paying the consultation fee for a physician consult to be issued a prescription. If approved, this prescription can only be filled at a local United States pharmacy of your choice. The prescription can not be filled at an internet, foreign, Canadian or internet version of a pharmacy. It is YOUR responsibility to make sure the pharmacy you choose 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 PRESCRIPTION FILLING SELECTION by selecting one of the four options below:

Option 1 : Regular Service - receive written prescription by mail in 7-15 days
Option 2 : EXPRESS Service - have prescription called into a local United States pharmacy within approximately 24 hours
If you selected Express service, confirm the name and phone number of your Local United States Pharmacy below:
Name, Phone # Address of EXPRESS Pharmacy

Click SUBMIT button for Physician Consultation for Soolantra® cream for Rosacea Treatment

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

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