Denavir Cream REFILL Form

Fields marked with an * are required

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Welcome back. After your initial consultation and Denavir approval each follow-up consultation, if approved, is only $75.00 plus processing. The refill consultation includes Denavir refill prescriptions for up till one year! Cold sores are a life long condition. There is no cure, but Denavir is PROVEN to effectively shorten outbreaks and decrease the discomfort of cold sore outbreaks. Denavir is the only FDA approved treatment for cold sores!

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.)

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The medical information you supply is subject to ALL patient/doctor privilege laws.

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FOLLOW UP - MEDICAL HISTORY

Medical Wellness Center Membership Number:

First and Last Name: *

Date of Birth (MM/DD/YY) *

Sex

Male
Female

Age

Did you experience any side effects:

If yes, have these symptoms resolved? If not, 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

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If you have ordered via Express service previously and had your prescription called into the pharmacy, you can choose to have your prescription for a year of refills called into the pharmacy again rather than receiving a 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 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

Express Info:

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PERSONAL AND PAYMENT INFORMATION

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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

Country

Phone *

Email *

Name of Credit Card Holder

Credit Card Type

Discover
Mastercard
Visa

Credit Card Number *

Expiration Date (MM/YY) *

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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

3 Digit Security Code *

BILLING ADDRESS:

Billing Zip Code

Credit Card Verification:

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.)

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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. Written prescription not available in CA, NY, MA, VT, RI, CT and IN (approximately 7- 15 days)
2. Have your prescription called into your local U.S. pharmacy 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.

Prescription method selection *

1. Receive Written prescription: (not available in CA, NY, MA, VT, RI, CT and IN)
2. Prescription called into your local pharmacy:
3. CA, NY, MA, VT, RI, CT and IN have to choose prescription ePRESCRIBED to your local pharmacy:

First, Check only ONE of the two 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. (Not available in CA, NY, MA, VT, RI CT and IN)

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 ($75 plus $9.50 processing). If you choose Express processing your credit card will be billed the $75 consultation fee plus $20 Express fee. 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 cannot 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 or Costco.com etc.)

If you selected Option 2 or 3, prescription called into or ePRESCRIBED to your local pharmacy, enter pharmacy information:

Next select Regular or Express Service *

REGULAR SERVICE:
EXPRESS SERVICE:

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 or ePRECRIBED 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.

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BY SUBMITTING THIS CONSULTATION FORM, I CERTIFY:

I Certify

I am 18 years of age or older.

I have been approved for Denavir by Medical Wellness Center Physicians and have been assigned a Membership number.

I have read and agree to Waiver of Liability.

I understand the side effects of this medication and adverse effect.

I do not have any of the contraindications to therapy.

I do not have a current prescription for Denavir from another physician.

I understand that my credit card will be billed $75.00 ($9.50 S& H) for this consultation if approved, and will provide Denavir refill Prescriptions good for one year. I understand and agree that once approved my credit card is charged the $75 consultation fee and that there are NO refunds or credits even if I change my mind or for any reason decide to discontinue use of Denavir.

I understand that no one under age 18 should use Denavir. I also understand that if pregnant, potentially pregnant or nursing women should not use Denavir. I understand if I have advanced HIV disease, compromised immune system, or have had any organ transplant I can not take Denavir. I also understand that there are no refunds, cancellations, or credits given under any circumstances even if I later decide not to take the medication for any reason.

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.

Confirmation of Selection

Option 1 : Receive Written Prescription (not available in CA, NY, MA, VT, RI, CT and IN)
Option 2: Have prescription CALLED or ePRESCRIBED to your local pharmacy

Please CONFIRM YOUR SELECTION made above of receiving written prescription or your prescription called into local U.S. pharmacy.

If you selected Option 2, prescription called into local pharmacy, confirm your pharmacy selection

Confirm choice of Regular or Express Service

Regular Service:
Express Service:

If you are choosing Option 2, to have your prescription called into your local United States 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.

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Click SUBMIT button (secure server) to order Denavir Refill Consultation

For any questions and fastest reply contact us by

email at wellnessmd@medicalwellnesscenter.com

Phone (United States Only): 617-367-8887

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