I am am an adult 18 years of age or older.
I have read and agree to Waiver of Liability.
I understand that Penlac Nail Lacquer is to be used EXTERNALLY only and only to be applied to the affected nails and immediately adjacent skin. Penlac is NOT to be used in the eyes, nose, mouth or vaginal area.
I understand that pregnant and nursing mothers should NOT use Penlac.
I am aware that in order to be eligible to receive a prescription, I must have been positively diagnosed as suffering from nail fungus infection, and I need to inform my doctor that I am using Penlac.
I understand that Penlac Nail Lacquer is not to be used by anyone under the age of 18, anyone with HIV disease or HIV-positive, anyone with diabetes or diabetic neuropathy, anyone who has been an organ or bone-marrow transplant recipient, a compromised immune system or by anyone who is using topical corticosteroids or steroid inhalers on a regular basis.
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 Penlac from another physician and I am not currently taking any other oral antifungal treatment for nail fungal infection nor am I currently using any antifungal topical treatments for nail fungal infection.
I understand that my credit card will be billed $75.00 and $9.50 or $20 S & H 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. Once submitting your refill request there are no cancellations of this service.
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.