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 Clarinex will not to be prescribed to anyone under the age of 18.

I understand that that pregnant and nursing mothers should not use Clarinex 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 allergies, and I need to inform my doctor that I am using Clarinex

I do not have any of the contraindications to therapy.

I do not have a current prescription for Clarinex from another physician, and I will not combine this antihistamine treatment, Clarinex, with any other prescription or over-the-counter antihistamine allergy medication.

I understand that my credit card will be billed $75.00 and $9.50 or $20 Express 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 75.00 consultation if approved and understand that there are no refunds for any circumstances even if I later change my mind and decide not to take the medication for any reason. I understand that once I submit my consultation for review there are absolutely NO cancellations.

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. I understand that if approved, I will receive a written prescription for Clarinex with 6 additional refills that can be filled at most any local United States Pharmacy of my choice. 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 or choose not to fill the prescription.

Clarinex Refill Form