VALTREX  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 VALTREX for 6 months  if approved.  If the consulting physician determines that Valtrex is not appropriate for you, there is NO charge for this consultation. Available in the United States Only. 

NOT AVAILABLE IN ILLINOIS AND ARKANSAS AND FLORIDA





Please be sure to read Valtrex 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 Valtrex 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:

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
Have you ever had any type of transplant such as kidney,heart,lung or bone marrow?YES  NO 
Are you on dialysis? YES  NO 
If female, are pregnant or presently breast feeding? YES  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? 
GENITAL HERPES HISTORY
Have you diagnosed with herpes by a physician in the past? Yes  No
Have you been examined and had positive herpes cultures by a doctor in the past? Yes  No
Have you been treated for herpes in the past? Yes  No
Please check how frequent you have recurrent herpes outbreaks?
1 to 2 outbreaks/yr 3 to 9 outbreaks/yr 10 or more outbreaks/yr
Please list types of treatment for genital herpes you've received: 
At what age were you first diagnosed with genital herpes?
Are you currently seeking Express treatment for a current outbreak or suppressive treatment for recurrent outbreaks?
Please describe you genital herpes outbreaks: frequency, duration, severity, whether frequency of outbreaks have increased or decreased etc.
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:
No PO boxes - physical address only
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 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.  I
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.
 

 
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 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. 
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 Valtrex is not to be taken by anyone under the age of 18, anyone with advanced HIV disease, anyone who has received a bone marrow transplant, kidney transplant or any organ transplant, has renal failure or compromised renal function or kidney disease, or a compromised immune system.
I understand that that pregnant and nursing mothers should not use Valtrex 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 recurrent genital herpes, and I need to inform my doctor that I am taking Valtrex.
I do not have any of the contraindications to therapy.
I do not have a current prescription for Valtrex from another physician, and I am not concurrently taking any other oral prescription medication  for genital herpes such as acyclovir.
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  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 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 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 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 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:
 


Click SUBMIT button for Physician Consultation for Valtrex
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
Email to contact Medicall Wellness CenterTo contact Medical Wellness Center -with any questions, please Email us.

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