Protopic Ointment INITIAL Consult Form Fields marked with an * are required not available in Illinois and Arkansas Please fill in all fields and respond to all questions honestly and completely so that a physician can review your consultation and prescribe Protopic ointment if approved. If the consulting physician determines that Protopic is not appropriate for you, there is NO charge for this consultation. You choose to receive a written prescription by mail or Express 24 hour service to your local pharmacy. Available only in the United States. Not available in Illinois and Arkansas and Florida HTML In order for Medical Wellness Center Physicians to provide you with the best care you need to reply honesty to all questions and you need to understand any and all risks and side effects associated with Protopic ointment. Please be sure to read Protopic CONTRAINDICATIONS, WARNINGS & SIDE-EFFECTS and confirm that you do NOT have any contraindications, understand the warnings and agree to the Waiver of Liability before filling out this consultation. Failure to answer truthfully and completely could result in serious consequences! Click here to read all the above stated contraindications before filling out the medical consultation form: I have read the previous Protopic 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: * HTML The medical information you supply is subject to ALL patient/doctor privilege laws. Divider medical history Medical History First and Last Name: * Date of Birth: * Age: Sex Male Female Divider Please List All Current Medical Conditions Do you take any prescription medication? Yes No If YES, please list all Prescription Medications you are currently taking: Please list all over-the-counter drugs you take regularly and why. Do you have any known allergies to Medicines? Yes No If Yes, please list any known Allergies to Medicines: Divider Copy Have you previously been diagnosed in the past to suffer from atopic dermatitis or eczema? Yes No Are you currently Pregnant, trying to become pregnant or Breast-feeding? Yes No Are you hypersensitive or allergic to tacrolimus, the active ingredient in Protopic Ointment or any inactive components? Yes No Components: tacrolimus, the active ingredient in Protopic Ointment or any inactive component: mineral oil, paraffin, propylene carbonate, white petrolatum and white wax? Do you suffer from Netherton's Syndrome? Yes No Do you have acute infectious mononucleosis? Yes No Do you CURRENTLY have any INFECTED, weeping, oozy eczema lesions? Yes No Have you ever had any type of transplant such as kidney, lung, heart or bone marrow? Yes No Do you have AIDS or a positive HIV test or have you recently been exposed to AIDS? Yes No Are you allergic to any creams or lotions or skin care products? Yes No If Yes, please explain: Are you currently using any topical PRESCRIPTION medications on your body? Yes No If yes, please explain in detail the areas of use and if it is on the area of the eczema lesions or a different area: Are you currently being treated for cancer? Yes No If yes, currently being treated for cancer, please explain: Have you had a physical exam in the last two years? Yes No Do you smoke? Yes No Do you consume more than 2 servings of alcohol per day? Yes No Divider Copy Copy current medical conditions Current Medical Conditions & Past Medical History Do you have or have you ever had any of the following conditions? Asthma Liver Disease Leukemia Skin Disease Compromised Immune System Coronary Artery Disease High Blood Pressure Thyroid Disease Allergies HIV Positive Sickle Cell Anemia Eczema Seizures Heart Disease Stroke Depression Hay Fever Kidney Disease Organ Transplant Sensitive Skin Anxiety Cancer Diabetes Endocrine Disorders None of the Above Are you currently taking steroids? Yes No Have you had surgery in the past three months? Yes No If yes, have had surgery in the last 3 months, please explain: Do you consider anything in your medical history to be relevant? If unsure, please ask your regular doctor Divider Copy Copy family history Family History Do any of your immediate family members have any of the following medical problems? Diabetes High blood pressure Kidney Disease Allergies Eczema or Atopic Dermatitis Liver Disease Heart disease Gallbladder disease Hay Fever Sensitive Skin Stroke Arteriosclerosis Cancer Asthma Skin Disease None of the Above Are there any other diseases than run in your family? Divider Copy Copy Copy eczema history Eczema Atopic Dermatitis History Have you diagnosed with eczema or atopic dermatitis by a physician in the past? Yes No Have you been treated for a eczema in the past? Yes No Please list types of treatment for eczema / atopic dermatitis you've received: Please check all, if any, of these treatments you have received in the past for eczema: Topical Steroids VA/UVB Phototherapy Antihistamines Other If checked other, please list: Are you currently on any treatments for your skin condition? * Yes No Protopic Ointment CANNOT be used along with topical steroids, UVA/UVB photo treatment or any other topical skin medication. These treatments have to stop in order to use Protopic Ointment. If yes, please detail ALL current treatments for your skin condition At what age were you first diagnosed with Eczema or Atopic Dermatitis? Please describe your eczema atopic dermatitis: * Describe appearance of lesions, size, color, location. Describe how frequently you have flare ups. And describe current condition of your skin -whether any or the eczema lesions are weeping, oozing, pus-filled... infected? Divider Copy Copy payment Personal and Payment Information HTML 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 Number: * Email Address: * Name on Credit Card: Credit Card Type: Visa Discover Mastercard Credit Card Number: * Expiration Date (credit card): * Card Verification Value (CVV) 3-Digit Security Code * Billing Address: Billing Zip Code: Yes, I AGREE * 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.) Divider HTML 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. The prescription can not be filled at an internet or .COM pharmacy such as Amazon.com, or at a foreign or Canadian pharmacyMedical 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. First, Choose REGULAR or EXPRESS Service: * REGULAR Service EXPRESS Service 1. First, choose whether you want REGULAR service (receive written prescription in 7-15 days) or EXPRESS 24 hour 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 which you can take to most any local United States pharmacy of your choice. (If you are from CA, NY, MA, VT, RI, CT and IN you can select regular service and your prescription will be Eprescribed to your local pharmacy) Processing fee $10.35EXPRESS SERVICE: Consult reviewed and prescription called/ePrescribed into most any local United States pharmacy of your choice within approximately 24 hours. Express processing fee $20 If you selected Express Service, please enter Express 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 California, New York, Massachusetts, Vermont, Rhode Island, Connecticut, or Indiana Clients: Option to Receive Written Prescription NOT available: 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. Select Protopic Ointment tube size: * Protopic Ointment 30 gm tube Protopic Ointment 60 gm tube 2. Next, select Protopic Ointment tube size:You can request either a 30gm or 60gm Protopic Ointment tube depending on your personal needs and the size of the area involved. Check below to indicate you choice of tube size: Divider By submitting this consultation form, I certify: * 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 burning, tingling, itching at site of application, and rarely increased risk of chicken pox, shingles, herpes simplex virus infection or eczema herpeticum.. I understand that Protopic Ointment 0.1% is not to be used by anyone under the age of 18, anyone with infected, oozing eczema skin lesions or anyone with Netherton's Syndrome. I understand that pregnant, attempting to become pregnant and nursing mothers should NOT use Protopic Ointment. I am aware that in order to be eligible to receive a Rx, I must have been positively diagnosed with eczema/ atopic dermatitis in the past, and I need to inform my doctor that I am using Protopic. I do not have any of the contraindications to therapy and I have read and understand the contraindications and possible side effects. I understand that I must NOT use Protopic Ointment with any other topical skin products or topical prescriptions, except moisturizers and sunblock. I do not have a current prescription for Protopic from another physician. I understand that my credit card will be billed $49.95 and $10.35 or $20 Express 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 $49.95 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. I understand that once I click SUBMIT button I can not cancel this consultation request 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. Divider Please CONFIRM your selection made above of Regular or Express Service: * REGULAR Service EXPRESS Service Confirm Pharmacy information if selected EXPRESS Service or you are from CA, NY, MA, VT, RI, CT and IN: If you selected EXPRESS Service or if you are from CA, NY, MA, VT, RI, CT and IN please confirm pharmacy information below: HTML Click SUBMIT button (secure server) to order Protopic Initial Consultation For any questions and fastest reply contact us by email at wellnessmd@medicalwellnesscenter.comPhone (United States Only): 617-367-8887 If you are a human seeing this field, please leave it empty.
