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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.
.
2. Next after making
this selection then 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.
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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 which are
headache,
nausea & abdominal pain and rarely allergic reactions ,
anaphylaxis,
and liver toxicity.
I understand
that Diflucan is not to be taken by anyone under the age of 18, anyone
with HIV disease, anyone with LIVER disease, anyone who
has
compromised renal function or kidney disease, or a compromised immune
system.
I
understand that pregnant and nursing mothers should NOT use
Diflucan.
I
am aware that in order to be eligible to receive a Rx, I must have been
positively diagnosed with a vaginal yeast infection due to
Candida
in the past, and I need to inform my doctor that I am taking
Diflucan.
I do
not have any of the contraindications to therapy and I have read and
understand
the contraindications and possible side effects
I do not have
a current prescription for Diflucan from another physician.
I
understand that my credit card will be billed $49.95 and $10.35
& H
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 S& H 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.
Please check here
if you are requesting our EXPRESS (available in
United States
only) review and processing of your
medical evaluation.
If approved your prescription will be called into a pharmacy
of your
choice within 24 hours. If you checked yes and you are
approved
you will be billed a $20 express S & H processing
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 SELECTION
made above of receiving written Rx, Express Service called into local
U.S.
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. |
PHONE
NUMBER:
(US ONLY) |
617-367-8887 |
Medical
Wellness Center
Boston, MA
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