Elimite Cream -Scabies:

ELIMITE 5% 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 ELIMITE CREAM if approved. If the consulting physician determines that Elimite is not appropriate for you, there is NO charge for this consultation. You choose to receive a written prescription by mail, 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 Elimite 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 Elimite 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 scabies or any other topical skin medication YES NO
If yes, please list topical 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

Do you have a know hypersensitivity to synthetic pyrethroid or pyrethrin, often used in veterinary pesticidesYES 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	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?

**SCABIES HISTORY**
Have you or household members or intimate contacts been diagnosed with Scabies by a physician in the past?Yes No
Have you been treated for scabies in the past? Yes No
Please list types of treatment for scabies you've received: Past treatments?
Please describe you scabies outbreaks: location, frequency, duration, severity, and any other family members affected
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 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. The prescription can not be filled in a Canadian or foreign pharmacy. 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.
Name, Phone # Address of EXPRESS Pharmacy

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 Elimite 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 without direct physician supervision.
I understand that that pregnant and nursing mothers should not use Elimite 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 or a family member or close contact must have been positively diagnosed with scabies , and I need to inform my doctor that I am using Elimite 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 for scabies.
I understand that Elimite cream is to be used EXTERNALLY ONLY! It is not to be used internally and it is not be used in the eyes.
I do not have a current prescription for Elimite from another physician, and I will not combine this scabies treatment,Elimite, with any other topical treatments for scabies other than over-the-counter soothing lotions such as Calamine lotion.
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 or I decide not to fill the prescription.
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 of receiving written prescription 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.


Click SUBMIT button for Physician Consultation for Elimite 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

To contact Medical Wellness Center -with any questions, please Email us.

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