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AVAILABLE IN UNITED
STATES ONLY
Services not available
in Arkansas, Illinois, or Florida
You can choose either Regular
or Express Service:
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
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 fill at most any local United
States pharmacy of your choice or your prescription. Processing fee $10.35
EXPRESS
SERVICE: Consult reviewed and prescription
called into most any local United States pharmacy of your choice within
approximately 24 hours. 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, 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 Drugstore.com or an internet
version of a local pharmacy such as CVS.com etc.
If you
selected Express service, enter the name and phone number of your Local
United States Pharmacy below:
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 Condylox Gel is not to be used by anyone under the age
of 18, anyone with advanced HIV disease, anyone with a severely compromised
immune system, anyone diagnosed with Bowenoid papulosis Squamous
cell carcinoma of the perianal/genital area..
I
understand that that pregnant and nursing mothers should not use Condylox
Gel 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 Condylox Gel. 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 Condylox Gel
is applied under the foreskin and I FAIL to retract the foreskin and make
sure the gel is completely dry before allowing opposing skin to touch.
I
understand that Condylox Gel is to be used EXTERNALLY ONLY! It is
not to be used internally in the cervical area, vagina, rectally, or urethra
or on mucous membranes.
I do not have
a current prescription for Condylox gel from another physician,
and I will not combine this genital warts treatment with any other
topical treatments for genital warts or genital herpes.
I
understand that a treatment cycle with Condylox gel consists of applying
the gel to the affected area twice a day for 3 consecutive days, stopping
for 4 consecutive days. The treatment area shall not exceed
1 1/2 square inches and the total Condylox gel applied in one day shall
not exceed 0.5 grams. This one week treatment cycle can only be repeated
for a total of 4 weeks. If genital warts have not cleared I understand
I must discontinue treatment and seek medical examination for alternative
treatments.
I
understand that my credit card will be billed $49.95 and $10.35 or
$20 express S & P 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 & P) 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.
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 of
receiving written Rx or Express Service called into local United States
pharmacy:
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:
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To
contact Medical Wellness Center -with any questions, please Email us.
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PHONE NUMBER:
(US ONLY) |
617-367-8887 |
Medical Wellness Center
Boston, MA
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