VaniqadoctorREFILLconsultform

VANIQA REFILL Consultation Form

Vaniqa Online Prescriptions for women's facial hair removal

Welcome back. After your initial consultation and Vaniqa approval each follow-up consultation, if approved, is only $75.00 and includes Vaniqa refill prescriptions good for 1 year (12 months of Vaniqa treatment without any further consult fees). In order to STOP unwanted facial hair regrowth you have to continue to use Vaniqa cream daily.

Please accurately and completely provide the following information in order for a physician to review your record. 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 Vaniqa is not appropriate for you, there is NO charge for this consultation. Available in the United States Only.

Not available in Arkansas, Illinois, or Florida

In order for Medical Wellness Center's Advanced Women's Medical Hair Removal 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 Vaniqa. Please be sure to read Vaniqa 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!
I have read the previous Vaniqa 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**
Medical Wellness Center Membership Number: First and Last Name: SEX: FemaleMale Date of Birth(MM/DD/YY): Current Age: Height (inches): Weight:

Please describe the effect Vaniqa cream 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)

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

Do you suffer from severe INFLAMMATORY Acne? YES NO

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

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 of the following conditions or problems listed below?

Fertility ProblemsYES NO
DiabetesYES NO
OverweightYES NO
Central Obesity(heavy upperbody/thin arms & legs)YES NO
Bruise Extremely Easily YES NO
Many Large Stretch MarksYES NO
AcneYES NO
Frontal Balding or Generalized Hair LossYES NO
Polycystic Ovary SyndromeYES NO
Cushing SyndromeYES NO
AcromagalyYES NO
Acanthosis Nigrans SyndromeYES NO
Adrenal HyperplasiaYES NO
Ovarian or Adrenal TumorYES NO
Menstrual Problems or IrregularitiesYES NO
If Yes, please explain Irregular? Absent?:

Endocrine or Hormonal ProblemsYES NO
If Yes, please explain:

Please check if you are Currently taking any of the following medications?
Phenytoin (Dilantin) Dizoxide Minoxidil
Cyclosporin Anavar Danazol

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	Polycystic Ovaries	Cushings
Liver disease	Ovarian Tumor	Adrenal Tumor
Leukemia	Acromagaly	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
Hirsutism(excesssive facial hair)	Polycystic Ovaries	Cushings
Are there any other diseases than run in your family?

**Hirsutism/Facial Hair History**
Have you diagnosed with a Hirsutism (excessive facial hair) by a physician in the past?Yes No
Do you feel that you have too much facial hair?Yes No
Please check all areas where you have unwanted facial hair: Upper Lip Chin Sideburns Temple Cheeks
Please check all areas, if any, besides your face that you have excessive body hair: Lower Abdomen Lower Back Upper Thighs Upper Arms Chest Nipples
Please describe your problem with excessive facial hair: Age first began to notice excessive hair growth, whether onset was sudden or gradual, whether condition progressing rapidly or slowly etc.
Have you been diagnosed by a physician with any medical conditions causing your excessive hair growth? YES Cushings Polycystic Ovaries Lower Abdomen Acromagaly Adrenal Hyperplasia Medication Related Ovary/Adrenal Tumor Other
How often do you need to remove unwanted facial hair (excluding eyebrow shaping? Daily Several Times/week Once/week Several Times/month Once/month Less than once/month
Please check all methods you currently use for removal of unwanted hair: Tweezing Waxing Laser Shaving Electrolysis Depilatory(like Nair/Neet) Other

**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 or faxed to Murray Avenue Apothecary 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 or faxed to Murray Avenue Apothecary 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 Drugstore.com or an internet version of a local pharmacy such as CVS.com etc.)
Name, complete Phone # including area code, Address of your Pharmacy:
3. Prescription faxed to Murray Avenue Apothecary:
Choose to have your prescription faxed to either Murray Avenue Apothecary and have the medication mailed directly to you.   If you select this choice you then must select below whether you want Murray Ave Apothecary .
Only if you selected to have your prescription faxed to and filled by Murray Avenue Apothecary please select your choice below:(It is imperative that you check first with the pharmacies on pricing of the medication. Medical Wellness Center only bills you for the consultation fee and the pharmacy you select will bill you directly for the medication itself. 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.)
Murray Avenue Apothecary:    412-421-4996
Please check here authorizing Murray Avenue Apothecary to fill your prescription, and your prescription will be forwarded to Murray Avenue Apothecary. 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 ($75.00 + 9.50 S & H or $20 if selecting express service. You need to call the pharmacy directly for pricing
If you are choosing to have your prescription called into your local pharmacy or faxed to Murray Ave Apothecary, 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 or faxed to Murray Ave 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 or faxed to Murray Ave in approximately 24 hours.

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 which are tingling, burning, folliculitis, skin rash, acne in less than 1% of users.
I understand that Vaniqa is not to be used on any other parts of the body than the face. I understand that Vaniqa is not a depilatory and I will have to continue using other methods of hair removal along with Vaniqa the first several weeks.
I understand that pregnant and nursing mothers should NOT use Vaniqa.
I am aware that in order to be eligible to receive a Rx, I must had a physical examination to rule out any serious underlying causes of hirsutism. I understand that treating the facial hair does not treat the underlying condition which may be as serious as Cancer or major Endocrine Disorders. I need to continue with all my regular primary health care and regular physical examinations, and I need to inform my doctor that I am taking Vaniqa.
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 Vaniqa from another physician.
I understand that my credit card will be billed $75.00 and $9.50 or #20 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 $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. I understand that once submitted, my request for a physician consultation can not be canceled.
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 prescription or your prescription called into a local U.S. pharmacy or receive your medication from Murray Avenue Apothecary:

Option 1: Receive written prescription by mail in 7-15 days.
Option 2: Prescription called into a local U.S. pharmacy. Please confirm pharmacy phone # below
Name, complete Phone # including area code
Option 3: Prescription faxed to Murray Avenue Apothecary

If you are choosing (Option 2, 3, or 4) to have your prescription called into your local pharmacy or faxed to Murray Ave Apothecary, please confirm selection of whether you want Regular service or Express service.
REGULAR SERVICE: No extra charge, regular processing fee of $9.50: Prescription called into your pharmacy or faxed to Murray Ave 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 or faxed to Murray Ave in approximately 24 hours.


Click SUBMIT button for Physician REFILL Consultation for Vaniqa
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 Advanced Medical Hair Removal - Vaniqa -with any questions, please Email us.

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