RENOVAdoctorconsultform

RENOVA Medical Consultation Form

RENOVA Online Prescriptions for fine lines wrinkles and hyperpigmentation

Please fill in all fields and respond to all questions honestly and completely so that a physician can review your consultation and prescribe RENOVA if approved. If the consulting physician determines that RENOVA is not appropriate for you, there is NO charge for this consultation. Available in the United States Only.
Not available in Illinois and Arkansas
In order for Medical Wellness Center's 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 RENOVA. Please be sure to read RENOVA 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! Service NOT available in Illinois and Arkansas and Florida Click here to read all the above stated conditions before filling out the medical consultation form: I have read the previous RENOVA 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.

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

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:

Are you currently Pregnant or Breast-feeding? YES NO

Are you currently trying to become pregnant? YES NO

Are you currently using any topical PRESCRIPTION medications on your face? YES NO
If yes, please explain:

Are you currently using any prescription or non prescription retinoid product such as Accutane, Retin-A, Retin-A Micro, Tretinoin, Retinol, isotrentinoin or an other Vitamin A product? YES NO If yes, please list which medications you are using, how long and why:

Are you currently being treated with RENOVA?YES NO If yes, please detail how long you have been using RENOVA and response:

Are you allergic to any creams or lotions or skin care products?YES NO
If yes, please explain:

Is your skin frequently red or irritated? YES NO
If yes, please explain:

Do you have any pre-existing or chronic skin disorders such as but not limited to eczema, actinic keratoses, or a history of skin cancer?
YES NO
If yes, please explain:

Do you have BLACK or Brown skin?YES NO

Are you extremely sensitive to the sun? YES NO

Have you undergone Laser Resurfacing or facial laser or photo therapy or a Medically administered glycolic or chemical peel in the last 6 months? YES NO

DO YOU CURRENTLY TAKE ANY OF THE FOLLOWING MEDICATION?

Photosensitizing Drugs?YES NO
Thiazides or Sulfa-containing Diuretics?YES NO
Diuretics?YES NO
Amiodarone?YES NO
Tretracyclines, Periostat, or quinolone antibiotics?YES NO
Fluoroquinolones?YES NO
Phenothiazines?YES NO
Sulfonamides or sulfa- drugs of any kind?YES NO
MinoxidilYES NO
Accutane, Retin-A or Vitamin A skin cream?YES NO
High Blood Pressure Medication?YES NO
If yes, please list:

Have you had a physical exam in the last two years?
YES NO

Are you currently taking steroids? YES NO

Do you smoke?YES NO

Do you consume more than 2 servings of alcohol per day?
YES NO

Have you had surgery in the last 3 months?
YES NO
If yes, please explain:

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

CURRENT MEDICAL CONDITIONS & PAST MEDICAL HISTORY
Do you have or have you ever had any of the following conditions?
Kidney Disease	Liver disease	Cushings
Eczema	Skin Disease	Skin Cancer
Leukemia	Mental Illness	Depression
Organ Transplant	Seizures	Anxiety
Coronary Artery Disease	Heart Attack	Heart disease
High Blood Pressure	Stroke	Diabetes
Thyroid Disease	Adrenal Disease	Endocrine Disorders

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
Eczema	Skin Diseases	Skin Cancer
Are there any other diseases than run in your family?

**Skin History**
Do you have heavily pigmented skin- Black or Brown skin?Yes No
Do you feel that you are getting fine wrinkles and/or hyperpigmented spots? Yes No
Do you have areas of hyperpigmentation - Brown spots from the sun?Yes No
Please check the description that most closely describes your skin: Very fair skin tone, blond or redhead, freckles, burns easily, never tans Light skin tone, will tan, but usually burns White to Olive skin tone, sometimes burns, auburn to light brown hair Medium brown skin tone, rarely burns Dark Brown Skin Tone, dark eyes, dark hair, very rarely burns African-American/Black, Very dark skin and eyes, burn resistant
Please tell us about the following qualities of your Skin: FACIAL LINES Few or none Some around the Eyes Around Eyes & Face Around Lips area Around Eyes, face & lips SKIN TEXTURE Bumpy & Uneven Smooth and Soft Coarse & Grainy
Please describe your skin and why you want to use RENOVA.
Please describe what your daily skin care regimen is.
Please list any plastic surgery, laser or medical peels or cosmetic procedure you have had in your lifetime on your face:

**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.***
**Service NOT available in Illinois and Arkansas and 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 hr 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.

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. If you would prefer to receive your medication by mail you can choose to have your prescription faxed to one of two approved local United States pharmacies that will mail your medication directly to you. The pharmacy will contact you and fill the prescription and mail the medication directly to you. (Medical Wellness Center has no financial ties to either of these pharmacies. They were chosen for their outstanding customer service, excellent compounding expertise, and reliability. They only dispense 100% FDA approved manufactured medications.)

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.

1. First choose whether you want to fill you prescription at your local U.S. pharmacy or at Murray Avenue Apothecary. Choose only ONE of these two choices.

Prescription filled at your local United States pharmacy:
Please check here if you are choosing to fill your prescription at your local United States pharmacy. If you want to purchase your prescription from your local pharmacy, you then can select whether you want to wait 7-15 days to receive your written prescription or whether you want Express service and your prescription is called into your local pharmacy in approximately 24 hours.

Murray Avenue Apothecary: 1-412-421-4996
Murray Avenue Apothecary is a specialized compounding pharmacy. This pharmacy has excellent pricing, especially for medications that are not covered by insurance or for those who do not have insurance. Only if you are choosing to fill your prescription online and have Murray Avenue Apothecary ship the medication to you check below:

Please check here authorizing Murray Avenue Apothecary to fill your prescription. Your prescription will be forwarded to Murray Avenue Apothecary. You must contact Murray Avenue Apothecary directly by phone ( 412-421-4996) for actual pricing of the medication, and to provide your payment and shipping information to the pharmacy. Your medication will be shipped directly to your shipping address that you provided to the pharmacy and you will be billed by Murray Avenue Apothecary for the medication . Medical Wellness Center will only bill you for the online consultation fee:

Regular service to Murray Avenue Apothecary- $49.95 consultation fee plus $10.35 processing fee to Medical Wellness Center for the online doctor visit. Consultation reviewed in 5-7 days.
Express Service to Murray Avenue Apothecary- $49.95 consultation fee plus $20 express fee. Consultation reviewed and your prescription faxed to Murray Avenue Apothecary pharmacy within approximately 24 hours.
If you have any questions in regards to shipping status and tracking information you need to contact the pharmacy directly: Murray Avenue Apothecary 412-421-4996.

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 3-5 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 called into most any local United States pharmacy of your choice or faxed to Murray Avenue Apothecary pharmacy 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. If you are selecting Murray Avenue Apothecary just write in your choice, you do not need to include phone number. 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 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
Name, Phone # Address of EXPRESS Pharmacy.

By submitting this consultation form, I certify:

I am am an adult 18 years of age or older and I am a genetic female.
I have read and agree to Waiver of Liability.
I understand the side effects of this medication include redness, peeling, stinging, or a feeling of warmth which may go away during course of treatment. If you experience Blistering, Crusting, Swelling, Excessive redness or peeling of your skin CHECK WITH YOUR DOCTOR AS SOON AS POSSIBLE!
I understand that RENOVA for TOPICAL us only and is to be used as part of a comprehensive skin care program and is NOT to be used on any other parts of the body than the face.
I understand that pregnant and nursing mothers should NOT use RENOVA, and I agree not to use RENOVA is I am trying to get pregnant.
I am aware that RENOVA increases sensitivity to sun and I agree to limit exposure to the sun, use SUNBLOCK daily and I agree NOT to use Tanning Beds or sunlamps of any sort. RENOVA is NEVER to be used on sunburned skin
I understand that RENOVA must be STOPPED for 3 - 4 weeks prior to any irritating skin procedures such as Electrolysis, Hair Depilatories, Waxes, Peels or laser or plastic surgery.
I understand that I am NOT to use Benzoyl Peroxide on my face at the same time I using RENOVA. I also understand that I am not to use any facial products that may be drying or irritating to the skin while using RENOVA.
I do not have any of the contraindications to therapy, I do not have eczema or any chronic skin condition, and I have read and understand the contraindications and possible side effects
I do not have a current prescription for RENOVA or Retin-A from another physician.
I understand that my credit card will be billed $49.95 and $10.35 S & H processing fees 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. I understand that once submitted, my request for a physician consultation can not be canceled. I understand that I will receive a written prescription for RENOVA 40g tube with 6 refills valid in any major local United States pharmacy of my choice.
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 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 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:
Name, Phone # Address of EXPRESS Pharmacy

Option 3: Murray Avenue Apothecary ships you the medication to your home - Regular Service: consult reviewed and faxed to Murray Avenue Apothecary in 5 - 7 days
Option 4: Murray Avenue Apothecary ships you the medication to your home - Express Service: consult reviewed and faxed to Murray Avenue Apothecary in approximately 24 hours

Click SUBMIT button for Physician Consultation for RENOVA

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 - RENOVA -with any questions, please Email us.

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