Acyclovir Topical co mpounded formulationsOnline Medical Consultation Form: Online Topical Acyclovir prescriptions for cold gential herpes and sore treatment(herpes simplex I)

Compounded Topical Acyclovir 5% Doctor Consultation:
Medical Evaluation Form

Please fill in all fields and respond to all questions honestly and completely so that a physician can review your consultation and prescribe compounded Topical Acyclovir if approved. If the consulting physician determines that Topical Acyclovir 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

Please be sure to read Topical Acyclovir 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. If you have NOT read these then- Click here to read all the above stated conditions before filling out the medical consultation form:

I have read the previous Topical Acyclovir contraindications and I do NOT have any of the stated contraindications. I understand the WARNINGS and I have read and agree to the Waiver of LiabilityYES 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:

Please list all current Prescription Medications:

Please list all over-the-counter drugs you take regularly and why:

Please list any known Allergies to Medicines:

Please list all past surgical history and dates:

Do you smoke?YES NO

Have you had a complete physical exam within the last 2 years?
Yes NO

Have you ever had any type of transplant such as kidney, heart, lung or bone marrow?YES NO

Are you on dialysis? YES NO

If female, are pregnant or presently breast feeding? 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?
Kidney Disease	Renal failure	Kidney dialysis
Liver disease	HIV Positive	Advanced HIV
Leukemia	Sickle Cell Anemia	Depression
Organ Transplant	Kidney Transplant	Bone Marrow Transplant
Compromised Immune System	Seizures	Anxiety
Coronary Artery Disease	Heart Attack	Heart disease
High Blood Pressure	Stroke	Diabetes
Thyroid disease	Depression	Endocrine Disorders

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

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
Are there any other diseases than run in your family?

**Please fill out below either Genital Herpes History or Cold Sore History or both according to whether you are seeking a prescription for genital herpes or cold sore outbreaks.**
**GENITAL HERPES HISTORY**
Have you diagnosed with herpes by a physician in the past? Yes No
Have you been examined and had positive herpes cultures by a doctor in the past? Yes No
Have you been treated for herpes in the past? Yes No
Please check how frequent you have recurrent herpes outbreaks? 1 to 2 outbreaks/yr 3 to 9 outbreaks/yr 10 or more outbreaks/yr
Please list types of treatment for genital herpes you've received: Past treatments?
At what age were you first diagnosed with genital herpes?
Are you currently seeking Express treatment for a current outbreak or suppressive treatment for recurrent outbreaks?
Please describe you genital herpes outbreaks: frequency, duration, severity, whether frequency of outbreaks have increased or decreased etc.

**COLD SORE HISTORY**
Have you diagnosed with Cold Sores (herpes simplex I) by a physician in the past?Yes No
Have you been treated for cold sores in the past? Yes No
Please check how frequent you have recurrent cold sore outbreaks? 1 to 2 outbreaks/yr 3 to 9 outbreaks/yr 10 or more outbreaks/yr
Please list types of treatment for cold sores you've received: Past treatments?
At what age did you first experience cold sores?
Are you currently seeking Express treatment for a current outbreak?
Please describe your cold sore outbreaks: frequency, duration, severity, whether frequency of outbreaks have increased or decreased etc. and location - on just lips, or chin or under nose ?

**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

Murray Avenue Apothecary: 412-421-4996

Murray Avenue Apothecary is a specialized compounding pharmacy who compounds several different Topical Acyclovir 5% formulations for genital herpes and cold sores. If you have any questions regarding specific formulations and/or ingredients, you need to contact Murray Avenue apothecary directly either by phone (412-421-4996) or email (susan@maapgh.com)
These compounded Topical Acyclovir formulations are only available from Murray Avenue apothecary. You must contact Murray Avenue Apothecary directly by phone ( 412-421-4996) or email (susan@maapgh.com) for actual pricing of the medication. 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 bills you for the online consultation fee:

1. First, Make your selection from below of the available compounded Topical Acyclovir formulations available from Murray Avenue Apothecary

Acyclovir Topical Cream 5% (for cold sores or genital herpes)
Acyclovir 5% + Hydrocortisone 0.5% Topical cream (for cold sores or genital herpes)
Acyclovir 5% + Lidocaine 1% Topical cream (for cold sores or genital herpes)
Acyclovir 5% + Lidocaine 2% + Hydrocortisone 1% Topical Cream (for cold sores or genital herpes)
Acyclovir 5% + Lidocaine HCL 5% + Deoxy-D-Glucose (2) 2% VAGINAL GEL (for genital herpes only)
Acyclovir 2% + Deoxy-D-Glucose(2) 0.2% LIP BALM (for Cold sores only)
Acyclovir 5% + Lidocaine 1% LIP BALM (for Cold sores only)

2. After making your selection of compounded Topical Acyclovir formulation, then choose whether you want regular service or Express 24 hour service.

Regular service to Murray Avenue Apothecary- $49.95 consultation fee plus $10.35 processing fee to Medical Wellness Center for the online doctor visit. Consultation reviewed in 5-7 days.
Express Service to Murray Avenue Apothecary- $49.95 consultation fee plus $20 express fee. Consultation reviewed and your prescription faxed to Murray Avenue Apothecary pharmacy within approximately 24 hours.
Regular service: Consult reviewed within approximately 3-7 business days $10.35
Express service: Consult reviewed and prescription faxed to Murray Avenue Apothecary within approximately 24 hours. (Please note that Murray Avenue Apothecary is only open Monday - Friday.) Express processing fee $20.

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.
I understand that no one under age 18 should use Topical Acyclovir unless directly prescribed by monitoring pediatrician. I understand if I have advanced HIV disease, compromised immune system, or have had any organ transplant I can not use Topical Acyclovir.
I understand that pregnant and nursing mothers should not use Topical Acyclovir because there are not sufficient studies. I understand that pregnant, potentially pregnant or nursing women should not use Topical Acyclovir .
I am aware that in order to be eligible to receive a prescription, I must have been positively diagnosed to suffer from recurrent genital herpes or cold sores, and I need to inform my doctor that I am using Topical Acyclovir.
I do not have any of the contraindications to therapy.
I do not have a current prescription for Topical Acyclovir from another physician, and I will not combine this genital herpes/cold sore treatment with any other topical genital herpes or cold sore treatments including Denavir.
I understand that my credit card will be billed $49.95 and $10.35 regular processing or $20 express processing for the medical consultation if approved (no refunds for this consultation service), if not approved there is no charge. I understand that by submitting this form I agree to pay the $49.95 consultation plus processing fee 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 not to take the medication for any reason. I understand that once I submit my consultation for review there are absolutely NO cancellations or no refunds.
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. Once submitting this consultation I can not receive a credit for the consultation service if I for any reason change my mind and no longer desire a prescriptions, or if I decide not to fill the prescription , or longer choose to use the medication.

Please CONFIRM YOUR SELECTION made above of Regular or Express Service:

Option 1: 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 2: Murray Avenue Apothecary ships you the medication to your home - Express Service: consult reviewed and faxed to Murray Avenue Apothecary in approximately 24 hours

If you have any questions in regards to shipping status and tracking information you need to contact the Murray Avenue Apothecary directly.


Click SUBMIT button for Physician Consultation for Topical Acyclovir
You may submit Consultation Form over the Internet by clicking the SUBMIT button. For any questions & fastest reply contact us by 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