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 include redness, peeling, stinging, or a feeling of warmth which may go away during course of treatment. If you experience Blistering, Crusting, Swelling, Excessive redness or peeling of your skin CHECK WITH YOUR DOCTOR AS SOON AS POSSIBLE!

I understand that Epiduo? Gel is for TOPICAL use only. Avoid eyes, angles of the nose, mucous membranes.

I understand that pregnant and nursing mothers should NOT use Epiduo? Gel, and I agree not to use Epiduo? Gel if I am trying to get pregnant.

I am aware that Epiduo? Gel increases sensitivity to sun and I agree to limit exposure to the sun, use SUNBLOCK daily and I agree NOT to use Tanning Beds or sunlamps of any sort. Epiduo? Gel is NEVER to be used on sunburned skin

I understand that Epiduo? Gel must be STOPPED for 3 - 4 weeks prior to any irritating skin procedures such as Electrolysis, Hair Depilatories, Waxes, Peels or laser or plastic surgery.

I understand that I am NOT to use Benzoyl Peroxide on my face at the same time I using Epiduo? Gel. I understand not to use alpha hydroxy, hydroxy or glycolic containing products. I also understand that I am not to use any facial products that may be drying or irritating to the skin while using Epiduo? Gel..

I understand that I am NOT to use any topical products containing sulfur, resorcinol or salicylic acid while using Epiduo? Gel.

I understand that I am NOT to use any abrasive soaps, astringents, alcohol-containing skin products on my skin while using Epiduo? Gel.

I understand that I am NOT to use any oil-based cosmetics or moisturizers. All cosmetics and moisturizers must be noncomedogenic or nonacnegenic.

I do not have any of the contraindications to therapy, I do not have eczema, sebborheic dermatitis or any chronic skin condition, and I have read and understand the contraindications and possible side effects

I do not have a current prescription for Retin A or Renova..

I do not have a current prescription for Epiduo? Gel from another physician. Medical Wellness Center does NOT fill prescriptions issued by other physicians nor do we sell or dispense medication.

I understand that my credit card will be billed $75.00 and $9.50 or $20 Express S & H for the refill 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 understand that I am not purchasing medication and can choose most major local United States pharmacy to fill the prescription. Prescriptions can not be filled at internet, foreign or Canadian pharmacies.

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.