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 Elimite Cream is not to be used by anyone under the age of 18, anyone with advanced HIV disease, anyone with a severely compromised immune system without direct physician supervision.
I understand that that pregnant and nursing mothers should not use Elimite Cream 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 or a family member or close contact must have been positively diagnosed with scabies , and I need to inform my doctor that I am using Elimite cream. I assume the responsibility for telling my primary physician about the prescription I receive from Medical Wellness Center.
I do not have any of the contraindications to therapy: I do NOT have advanced HIV. I do NOT have a severely compromised immune system. I am NOT pregnant or breast feeding. I am not concurrently using another topical medication for scabies.
I understand that Elimite cream is to be used EXTERNALLY ONLY! It is not to be used internally and it is not be used in the eyes.
I do not have a current prescription for Elimite from another physician, and I will not combine this scabies treatment,Elimite, with any other topical treatments for scabies other than over-the-counter soothing lotions such as Calamine lotion.
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 (plus S & H) if approved and understand that there are no refunds for any circumstances even if I later change my mind and decide not to use the medication for any reason or I decide not to fill the prescription.

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. 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.