ALDARA CREAM  Dr. 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 ALDARA CREAM if approved. You will be prescribed 1 box of 24 packets of Aldara cream with 3 refills.  If the consulting physician determines that Aldara  is not appropriate for you, there is NO charge for this consultation. You choose to receive a written prescription by mail or Express 24 hour service to your local United States pharmacy.

Available only in the United States.
 Not available in Illinois and Arkansas and Florida



Please be sure to read Aldara 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 Aldara 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 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:

Are you currently using any topical medication for genital warts or any other topical medication on the genital area YES  NO 
If yes, please list topical genital medication presently using:

 

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
Do you suffer from advanced AIDS (HIV)?YES NO 
Do you have a severely compromised immune system?YES  NO 
If female, are pregnant or presently breast feeding? YES  NO 
If male, are you circumcised?YES  NO 
Please Note: If you are not circumcised, if applying Aldara cream under the foreskin you need to retract the foreskin daily and thoroughly wash and dry the area. FAILURE TO DO SO CAN LEAD TO SCARRING, STRICTURING & COULD NECESSITATE CIRCUMCISION!

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 BoneMarrow Transplant
Compromised ImmuneSystem 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? 
GENITAL WARTS HISTORY
Have you diagnosed with genital warts, perianal warts or condylomata acuminata   by a physician in the past?Yes No
Have you been treated for genital warts in the past? Yes  No
Please list types of treatment for genital warts you've received: 
Please check how frequent you have recurrent genital warts outbreaks? 
1 to 2 outbreaks/yr 3 to 9 outbreaks/yr10 or more outbreaks/yr
Please describe you genital warts outbreaks: location, frequency, duration, severity, whether frequency of outbreaks have increased or decreased etc. 
At what age were you first diagnosed with genital warts? 
Are you currently seeking Express treatment for a current outbreak ? If yes please indicate  in the appropriate area on the form below that you request EXPRESS SERVICE. 
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 3-7 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.
Please CONFIRM YOUR SELECTION made above:
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:
 
 


Click SUBMIT button for Physician Consultation for Aldara cream
You may submit Consultation Form over the Internet 
by clicking the SUBMIT button (secure server). 

For any questions & fastest reply contact us by
email at wellnessmd@medicalwellnesscenter.com
Email to contact Medicall Wellness CenterTo contact Medical Wellness Center -with any questions, please Email us.

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