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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.
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 3-7
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. 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.
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 Aldara Cream is not to be used by anyone under the age
of 18, anyone with advanced HIV disease, anyone with a
severely compromised
immune system.
I
understand that that pregnant and nursing mothers should not use Aldara
Cream because there are not sufficient studies and I am not pregnant or
nursing.
I
am aware that in order to be eligible to receive a Rx, I must have been
positively diagnosed to suffer from genital warts, and I need to inform
my doctor that I am using Aldara cream. I assume the responsibility for
telling my primary physician about the prescription I receive from
Medical
Wellness Center.
I
do not have any of the contraindications to therapy: I do NOT have
advanced
HIV. I do NOT have a severely compromised immune system. I am NOT
pregnant
or breast feeding. I am not concurrently using another topical
medication
to the genital/perianal area.
I
understand that if I am an uncircumcised male, there is a risk of
scarring
and stricturing which may ultimately lead to circumcision if Aldara
cream
is applied under the foreskin and I FAIL to daily retract the foreskin
and thoroughly wash and dry the area.
I
understand that Aldara cream is to be used EXTERNALLY ONLY! It is not
to
be used internally in the cervical area, vagina, rectal, or
urethra.
I
do not have a current prescription for Aldara from another
physician,
and I will not combine this genital warts treatment, Aldara,
with
any other topical treatments for genital warts or genital
herpes.
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), if not approved there is no charge. I understand
that by
submitting this form I agree to pay the $49.95
consultation
(plus S & H) if approved and understand that there are no
refunds for
any circumstances even if I later change my mind and decide
not to
use the medication for any reason.
Please
check here if you are requesting our EXPRESS
review
(available in the United States only) and processing of your
medical
evaluation. If approved your prescription will be
called into
a local U.S. 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
certify that 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 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 choose to use
the medication.
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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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