Penlac Refill Doctor Consult Form

PENLAC REFILL Medical Consultation Form

Penlac prescription for nail fungus infection online

Welcome back. After your initial consultation and Penlac Nail Lacquer prescription approval each follow-up consultation, if approved, is only $75.00 and includes 12 Penlac refill prescriptions valid for 1 year. You must include your Medical Wellness Center Membership Number which was assigned upon approval into the program. If you don't have this available, you can Email us for your membership number.) If the consulting physician determines that Penlac refills are not appropriate for you, there is NO charge for this consultation.
In order for Medical Wellness Center Physicians to provide you with the best care you need to reply honesty to all questions and you need to understand any and all risks and side effects associated with Penlac. Please be sure to read Penlac CONTRAINDICATIONS, WARNINGS & 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. Failure to answer truthfully and completely could result in serious consequences !
Click here to read all the above stated conditions before filling out the medical consultation form: I have read the previous Penlac 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 Liability:YES NO

The medical information you supply is subject to ALL patient/doctor privilege laws.
Not Available in Arkansas, Florida or Illinois

**MEDICAL HISTORY**
First and Last Name: Medical Wellness Center Membership Number: SEX: FemaleMale Date of Birth(MM/DD/YY): Current Age: Height (inches): Weight:

Please describe the effect Penlac Nail Lacquer had for you:

Did you experience any side effects: YES NO
IF yes, have these symptoms resolved? YES NO

If yes, please describe symptoms:

Have there been any changes in your current medical conditions that the consulting Physician should be aware of?
(If yes, be sure to also consult you regular primary care physician, symptoms could be unrelated to current treatment and related to some other condition)

CLICK HEREYou can choose to have your prescription for a year of refills called into the pharmacy rather than receiving a prescription by mail. If approved, your prescription will be called into any US pharmacy of your choice There is no extra charge for this service for refill prescriptions and your credit card will be billed the $75 consultation fee and regular S & H processing fee of $ 9.50. If you are requesting your prescription to be called into your pharmacy, please enter the complete phone# including area code, name and address of pharmacy where you choose to fill your prescription

Please list all current Medical Conditions:

Do you take any prescription medication?YESNO
If YES, please list all Prescription Medications you are currently taking and the length of time taking each of them: For example: Claritin -4yrs; Zoloft- 6mo, etc.

Please list all over-the-counter drugs you take regularly and why.
For example: aspirin -for migraines, Unisom -difficulty sleeping etc.

Do you have any known allergies to Medicines?YES NO
If Yes, please list any known Allergies to Medicines:

Have you previously been diagnosed to have nail fungus infection YES NO

Are you currently Pregnant or Breast-feeding? YES NO

Do you have a history of immunosuppression or a compromised immune system? YES NO

Are you currently using a steroid inhaler on a regular basis or are you currently using topical corticosteroid creams on a regular basis? YES NO

Are you currently being treated for cancer?YES NO
If yes, please explain:

Are you currently taking Dilantin or Phenytoin or other Anti-Seizure Medication for epilepsy? YES NO

Have you ever had any type of transplant such as kidney, lung, heart or bone marrow?YES NO

Do you have diabetes or diabetic neuropathy? YES NO

Do you have AIDS or a positive HIV test ?YES NO

Are you currently taking oral antifungal treatment for nail fungus infection? YES NO
If yes, please explain:

Are you currently using any topical antifungal treatment for nail fungus infection? YES NO
If yes, please explain:

Have you had a physical exam in the last two years?YES NO
	Do you smoke?YES NO
Do you consume more than 2 servings of alcohol per day? YES NO

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	Yeast/fungus infection
Leukemia	Sickle Cell Anemia	Depression
Organ Transplant	BoneMarrow Transplant	Cancer
Compromised ImmuneSystem	Seizures	Asthma
Coronary Artery Disease	Heart Attack	Heart disease
High Blood Pressure	Stroke	Diabetes
Thyroid disease	Depression	Endocrine Disorders

Are you currently taking steroids? YES NO

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	Nail fungal Infection
High blood pressure	Heart disease	Arteriosclerosis
Kidney Disease	Gallbladder disease	Cancer
Are there any other diseases than run in your family?

Nail Fungus Infection History

Have you diagnosed with a nail fungus infection in the past by a physician in the past?Yes No

Have you been treated for a nail fungus infection in the past?Yes No

Please list types of treatment for nail fungus infections you've received: Past treatments?</b></b></b></b>

Do you have a family history of nail fungal infections? YES NO
If yes, please explain:

At what age did you first experience a nail fungus infection?

Please describe your nail fungus infection: finger nail and/or toe nail involvement, how many nails involved and how much of nail infected, how long infection has been present duration, severity and if you have pain, swelling or disability as a result of the nail fungus infection..

Please check the photo that best describes the extent of your fungal nail infection:
Mild	Moderate	Severe

**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
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.

For refill prescriptions you have the option of:

1. Receiving a WRITTEN prescription by mail which you can fill at most any local United States pharmacy of your choice (approximately 7- 15 days)
2. Have your prescription called into your local U.S. pharmacy at NO EXTRA charge in 3 - 7 days, COMPLEMENTARY call in service.

If you select option # 2, you can also select EXPRESS 24 hour processing where your prescription will be called into your local pharmacy in approximately 24 hours. If you select EXPRESS 24 hour processing you will be charged a $20 express processing service fee rather than the regular processing fee of $9.50.
Please check here if your are selecting EXPRESS 24 hours service - $20 express processing fee

Check only ONE of the three choices below:

1. Receive Written prescription:
Receive written prescription in approximately 7- 15 days which you can fill at most any local United States pharmacy of your choice.
2. Prescription called into your local pharmacy:
Prescription for one year of refills called into any major local United States pharmacy of your choice rather than receiving a written prescription by mail. If approved, your prescription will be called into a pharmacy of your choice. There is no extra charge for this service for refill prescriptions (unless you are choosing the Express Refill call in service) and your credit card will be billed the $75 consultation fee and regular S & H processing fee of $ 9.50. If you are requesting your prescription to be called into your pharmacy, please enter the 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.)

Name, complete Phone # including area code, Address of your Pharmacy:

If you are choosing to have your prescription called into your local pharmacy, please select whether you want Regular service or Express service.

REGULAR SERVICE: No extra charge, regular processing fee of $9.50: Prescription called into your pharmacy in 3-7 days.
EXPRESS SERVICE: $20 express processing fee instead of the $9.50 regular processing fee- your prescription will be called into your local pharmacy in approximately 24 hours.

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 that Penlac Nail Lacquer is to be used EXTERNALLY only and only to be applied to the affected nails and immediately adjacent skin. Penlac is NOT to be used in the eyes, nose, mouth or vaginal area.
I understand that pregnant and nursing mothers should NOT use Penlac.
I am aware that in order to be eligible to receive a prescription, I must have been positively diagnosed as suffering from nail fungus infection, and I need to inform my doctor that I am using Penlac.
I understand that Penlac Nail Lacquer is not to be used by anyone under the age of 18, anyone with HIV disease or HIV-positive, anyone with diabetes or diabetic neuropathy, anyone who has been an organ or bone-marrow transplant recipient, a compromised immune system or by anyone who is using topical corticosteroids or steroid inhalers on a regular basis.
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 Penlac from another physician and I am not currently taking any other oral antifungal treatment for nail fungal infection nor am I currently using any antifungal topical treatments for nail fungal infection.
I understand that my credit card will be billed $75.00 and $9.50 or $20 S & 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 $75.00 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. Once submitting your refill request there are no cancellations of this service.
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 or your Rx called into local U.S. pharmacy:

Option 1 : receive written prescription by mail in 7-15 days.
Option 2 : have prescription called into a local U.S. pharmacy. Please confirm pharmacy phone # below
Name, complete Phone # including area code

If you are choosing (option 2) to have your prescription called into your local pharmacy, please confirm your selection of whether you want regular service or Express service.

Regular Service: No extra charge 3 - 7 days : Prescription called into your pharmacy in 3-7 days- complementary.
Express Service: $20 express processing fee - your prescription will be called into your local pharmacy in approximately 24 hours or less.


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