ELIMITE 5% Scabies Cream 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 ELIMITE CREAM if approved. If the consulting physician determines that Elimite is not appropriate for you, there is NO charge for this consultation. You choose either to receive a written prescription by mail or choose Express 24 hour service and your prescription is called into your local United States pharmacy.

Available only in the United States.

Not available in Illinois and Arkansas and Florida

Please be sure to read Elimite contraindications, warnings, and 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. If you have NOT read these then- Click here to read all the above stated conditions before filling out the medical consultation form:

I have read the previous Elimite 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:

medical confidentiality

The medical information you supply is subject to ALL patient/doctor privilege laws.

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Medical History

First Name: *

Date of Birth *

Current Age

Sex

Height (inches)

Weight (pounds)

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Please list all current Medical Conditions

Please list all current Prescription Medications:

Are you currently using any topical medication for scabies or any other topical skin medication?

If yes, please list topical Scabies medication presently using:

Please list all over-the-counter drugs you take regularly and why:

Do you have any known allergies to Medicines?

If Yes, please list any known Allergies to Medicines:

Please list all past surgical history and dates:

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Do you smoke?

Have you had a complete physical exam within the last 2 years?

Do you suffer from advanced AIDS (HIV)?

Do you have a severely compromised immune system?

If female, are pregnant or presently breast feeding?

Do you have a know hypersensitivity to synthetic pyrethroid or pyrethrin, often used in veterinary pesticides?

How often alcoholic beverages do you drink?

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medical conditions

Current Medical Conditions & Past Medical History

Do you have or have you every had any of the following conditions?

Kidney Disease
Liver Disease
Leukemia
Organ Transplant
Compromised ImmuneSystem
Coronary Artery Disease
High Blood Pressure
Thyroid Disease
Renal failure
HIV Positive
Sickle Cell Anemia
Kidney Transplant
Seizures
Heart Attack
Stroke
Depression
Kidney dialysis
Advanced HIV
BoneMarrow Transplant
Anxiety
Heart disease
Diabetes
Endocrine Disorders
None of the Above

Are you currently taking steroids?

Are you currently being treated for cancer?

If yes, currently being treated for cancer, please explain:

Have you had surgery in the last 3 months?

If yes, 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

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family history

Family History

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

Diabetes
High blood pressure
Kidney Disease
Liver Disease
Heart disease
Gallbladder disease
Stroke
Arteriosclerosis
None of the Above
Cancer
None of the Above

Are there any other diseases than run in your family?

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Scabies History

Have you or household members or intimate contacts been diagnosed with Scabies by a physician in the past?

Have you been treated for scabies in the past?

Please list types of treatment for scabies you've received:

Please describe your scabies outbreaks: location, frequency, duration, severity, and any other family members affected *

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payment

Personal and Payment Information

availability

Available in the United States Only
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

Enter Credit Card Number: *

Expiration Date: *

Enter 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.)

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fill prescription

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 pharmacy

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.

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Choose wether you want REGULAR or EXPRESS Service: *

REGULAR Service
EXPRESS 24 hr Service

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. (Written prescription not available in MCA, NY, MA, VT, RI, CT and IN. Instead, with Regular Service, your prescription Epresribed directly to your local pharmacy.) Processing fee $10.35

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

If you selected EXPRESS Service, Enter 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.

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.
I understand that Elimite Cream is not to be used by anyone under the age of 18, anyone with advanced HIV disease, anyone with a severely compromised immune system without direct physician supervision.
I understand that that pregnant and nursing mothers should not use Elimite Cream because there are not sufficient studies and I am not pregnant or nursing.
I am aware that in order to be eligible to receive a Rx, I or a family member or close contact must have been positively diagnosed with scabies , and I need to inform my doctor that I am using Elimite cream. I assume the responsibility for telling my primary physician about the prescription I receive from Medical Wellness Center.
I do not have any of the contraindications to therapy: I do NOT have advanced HIV. I do NOT have a severely compromised immune system. I am NOT pregnant or breast feeding. I am not concurrently using another topical medication for scabies.
I understand that Elimite cream is to be used EXTERNALLY ONLY! It is not to be used internally and it is not be used in the eyes.
I do not have a current prescription for Elimite from another physician, and I will not combine this scabies treatment,Elimite, with any other topical treatments for scabies other than over-the-counter soothing lotions such as Calamine lotion.
I understand that my credit card will be billed $49.95 and $10.35 S & H for the 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 $49.95 consultation (plus S & H) if approved and understand that there are no refunds for any circumstances even if I later change my mind and decide not to use the medication for any reason or I decide not to fill the prescription.

I certify that 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 for the consultation if approved. Once submitting this consultation I can not receive a credit for the consultation service if I for any reason change my mind and no longer choose to use the medication.

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REFILL Please CONFIRM YOUR SELECTION of Regular or Express Service: *

REGULAR Service
EXPRESS Service

If requesting Express Service of are from CA, NY, MA, VT, RI, CT and IN confirm pharmacy information below:

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Click SUBMIT button (secure server) to order Elimite Cream 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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