Diflucan Consult Form
Fields marked with an * are required

Please fill in all fields and respond to all questions honestly and completely so that a physician can review your consultation and prescribed Diflucan if approved. You will have a choice of Express Service and your prescription can be called into a local pharmacy of your choice in approximately 24 hours.  If the consulting physician determines that Diflucan is not appropriate for you, there is NO charge for this consultation.

NOT  AVAILABLE IN ILLINOIS AND ARKANSAS AND FLORIDA

WARNING: Do not take Diflucan if your are pregnant, trying to get pregnant or breastfeeding 
I have read the previous Diflucan 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:

MEDICAL HISTORY
Sex:
Do you take any prescripton medications?
Do you have any known allergies to medicines?
Have you previously been diagnosed in the past to have vaginal yeast infections or vaginal candadiasis?
Are you currently Pregnant, trying to get pregnant, or Breast-feeding?
Are you currently taking Propulsid or Cisapride?
Do you presently have acute symptoms of severe abdominal pain? Fever? Chills? Nausea or Vomiting?
Do you have a FOUL-SMELLING/YELLOW-GREEN Vaginal Discharge (This is different from the typical clumpy or cottage-cheese like discharge seen with vaginal yeast infections?
Do you have LIVER DISEASE, RENAL or KIDNEY disease or are you on Dialysis?
Do you have diabetes?
Do you currently take Oral Hypoglycemics or Sulfonylurea oral hypoglycemic agents for controlling blood sugar such as TOLABUTAMIDE? GLIPIZIDE? GLYBURIDE?
Do you have AIDS or a positive HIV test or have you recently been exposed to AIDS?
Are you currently taking Rifabutin or Ansamycin Mycobutin or Rifampin or Cyclosporine or AmphotericinB or Tacrolimus?
Are you currently taking THEOPHYLLINE, Seldane (Terfenadine) or HISMANAL (Astemizole) or Singulair or Accolate or other anti-asthma drugs?
Are you currently taking Dilantin or Phenytoin or Anti-Seizure Medication?
Are you currently taking Warfarin or Coumarin-type anticoagulants?
Do you have or have you ever had Tuberculosis?
Are you currently being treated for cancer?
Have you had a physical exam in the last two years?
Do you smoke?
Do you consume more than 2 servings of alcohol per day?

CURRENT MEDICAL CONDITIONS and PAST MEDICAL HISTORY
Do you have or ever had any of the following conditions?
Are you currently taking steroids?
Have you had surgery in the last 3 months?

If unsure, please ask your regular doctor

FAMILY HISTORY
Do any of your immediate family members have any of the following medical problems?

VAGINAL YEAST INFECTION HISTORY
Have you diagnosed with a vaginal yeast infection by a physician in the past?Yes/No *
Have you been treated for a vaginal yeast infection in the past?

PERSONAL and PAYMENT INFORMATION

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

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.)

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 (not available in CA, NY, MA, VT, RI, CT and IN - prescription Eprescribed to your local pharmacy), or to have your prescription called/Eprescribed into your local United States pharmacy.

EXPRESS Service available: Your prescription is reviewed and prescription sent to pharmacy in approximately 24 hours or less.

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.
Choose REGULAR SERVICE ( receive written prescription in 7-15 days) or EXPRESS SERVICE: *

REGULAR SERVICE:  Consult reviewed within approximately 3-7 business days and you will receive a written prescription by mail in approximately 7- 15 days. You can fill this prescription at most any local United States pharmacy of your choice. (For CA, NY, MA, VT, RI, CT and IN, Regular Service prescription Eprescribed to your local pharmacy) Regular processing fee $10.35

EXPRESS SERVICE:   Consult reviewed and prescription called or Eprescribed into most any local United States pharmacy of your choice within approximately 24 hours.  Express processing fee $20

The prescription can only be called into your local United States 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 RECEIVE WRITTEN Prescription to fill at your local California, New York, Massachusetts, Vermont, Rhode Island, Connecticut, or Indiana pharmacy, the prescription has to be ePrescribed.  These states, CA, NY, MA, VT, RI, CT, and IN,  will not accept written prescriptions.  Please enter the NAME, ADDRESS and Phone number of your local California, New York, Massachusetts, Vermont, Rhode Island, Connecticut, or Indiana pharmacy.
REGULAR Service your consult will be processed in 3-7 business days.  EXPRESS Service in approximately 24 hours.
  • 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 which are headache, nausea & abdominal pain and rarely allergic reactions , anaphylaxis, and liver toxicity.  
  • I understand that Diflucan is not to be taken by anyone under the age of 18, anyone with HIV disease,  anyone with LIVER disease, anyone who has  compromised renal function or kidney disease, or a compromised immune system.  
  • I understand that pregnant and nursing mothers should NOT use Diflucan.  
  • I am aware that in order to be eligible to receive a Rx, I must have been positively  diagnosed with a vaginal yeast infection due to Candida in the past,  and I need to inform my doctor that I am taking Diflucan.  
  • 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 Diflucan from another physician.  
  • I understand that my credit card will be billed $49.95 either $10.35 or $20 express processing  for the medical consultation if approved. If not approved there is NO charge.  I understand that by submitting this form I agree to pay the $49.95 consultation plus processing, if approved. I 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.  
  • 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
INTIAL Consult Please CONFIRM YOUR SELECTION made above: *

Click SUBMIT button (secure server) to order Diflucan Initial Consultation

For any questions and fastest reply contact us by

email at wellnessmd@medicalwellnesscenter.com

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