Zovirax (acyclovir) REFILL Form

Fields marked with an * are required

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

NOT AVAILABLE IN ILLINOIS AND ARKANSAS AND FLORIDA

I have read the previous Zoviraz (acyclovir) pages and I do NOT have any of the stated contraindications. I understand the WARNINGS and I have read and agree to the Waiver of Liability:

Click here to read the stated contraindications before filling out the medical consultation form:

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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

First and Last Name: *

Medical Wellness Center Membership Number:

Date of Birth (MM/DD/YY) *

Sex

Male
Female

Age

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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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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

Phone *

Email *

Name of Credit Card Holder

Credit Card Type

Credit Card Number *

Expiration Date (MM/YY) *

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
You can choose either to receive a written prescription by mail which you can fill at your local United States pharmacy, or to have your prescription called into your local United States pharmacy, or have your prescription forwarded to Murray Avenue Apothecary and receive the actual medication by mail.
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.

1. First, choose whether to receive a written prescription, prescription called into local pharmacy, or to be filled by Murray Avenue Apothecary * *

RECEIVE WRITTEN PRESCRIPTION (not available MA, NY, and CA)
PRESCRIPTION CALLED INTO YOUR LOCAL PHARMACY:
PRESCRIPTION FORWARDED TO MURRAY AVENUE APOTHECARY:

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 for MA and NY and CA pharmacies)

2. PRESCRIPTION CALLED INTO LOCAL PHARMACY: Prescription for one year of refills called into most any local United States pharmacy of your choice rather than receiving a written prescription by mail. There is no extra charge for this service for refill prescriptions (unless you are choosing the Express Refill call in service). Your credit card will be billed the $75 consultation fee plus regular processing. If you are requesting your prescription to be called into your pharmacy, you will need to enter the complete phone# including area code, name and address of pharmacy where you choose to fill your prescription

3. PRESCRIPTION FORWARDED TO MURRAY AVENUE APOTHECARY: Choose to have your prescription forwarded to Murray Avenue Apothecary and have the medication mailed directly to you. If you select this choice, it is suggested that you check first with Murray Ave Apothecary regarding pricing of the medication. Medical Wellness Center only bills you for the consultation fee ($75 and either $9.50 Regular or $20 Express processing). Murray Ave Apothecary will bill you directly for the medication itself. If you have any questions in regards to medication costs, whether they can ship to your location, shipping status or tracking information, you need to contact the pharmacy directly: Murray Avenue Apothecary 412-421-4996 or pharmacist@MAAPGH.com

If you selected Option 2 above, to have your prescription called into a local U.S pharmacy, provide pharmacy information below:

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.

ATTENTION Massachusetts and New York and California Clients: Option to Receive Written Prescription NOT available:

If you selected RECEIVE WRITTEN Prescription to fill at your local Massachusetts or New York or California pharmacy, the prescription has to be ePrescribed. Massachusetts, New York, and California will not accept written prescriptions. Please enter the NAME, ADDRESS and Phone number of your local Massachusetts or New York or California pharmacy. REGULAR Service your consult will be processed in 3-7 business days. EXPRESS Service in approximately 24 hours.

2. Next, if you are choosing to have your prescription called into your local pharmacy or sent to Murray Avenue Apothecary, select REGULAR or EXPRESS Service: *

REGULAR SERVICE:
EXPRESS SERVICE:

REGULAR SERVICE: No extra charge, regular processing fee of $9.50: Prescription called into your pharmacy or forwarded to Murray Ave 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 or forwarded to Murray Ave 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 previously approved for Zovirax (acyclovir) cream prescription 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 Zovirax (acyclovir) cream from another physician.
I understand that my credit card will be billed $75.00 ($9.50 or $20 processing fee) for this consultation if approved, and will provide Zovirax (acyclovir) cream 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 Zovirax (acyclovir) cream.
I understand that no one under age 18 should use Zovirax (acyclovir) cream unless under direct supervision by a pediatrician.
I also understand that if pregnant, potentially pregnant or nursing women should not use Zovirax (acyclovir) cream.
I understand if I have advanced HIV disease, compromised immune system, or have had any organ transplant I can not use Zovirax (acyclovir) cream.
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.

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REFILL Please CONFIRM YOUR SELECTION made above: *

Option 1: REGULAR Service: Receive written prescription by mail in 7-15 days (Not available in MA and NY and CA)
Option 2 : REGULAR Service: Have prescription called or Eprescribed into a local U.S. pharmacy in 3-7 business days
Option 3 : EXPRESS Service: Have prescription called or Eprescribed into a local U.S. pharmacy in approximately 24 hours
Option 4: Regular Murray Avenue Apothecary Service: Prescription forwarded to pharmacy in 3-7 business days
Option 5: Express Murray Avenue Apothecary Service: Prescription forwarded to pharmacy in approximately 24 hours

If you are requesting prescription called/ePRESCRIBED into your local pharmacy, confirm pharmacy information

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Click SUBMIT button (secure server) to order Zovirax 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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