Kerydin Topical Solution 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 prescribe Kerydin Topical Solution if approved. If the consulting physician determines that Kerydin is not appropriate for you, there is NO charge for this consultation. 

Available in the United States Only.  

Not available in Illinois or Arkansas or Florida


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 Kerydin.   Please be sure to read Kerydin 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 Kerydin contraindications and warnings before filling out consult form:

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

Medical History
Do you take any prescription medication?
Do you have any known allergies to Medicines?
Have you previously been diagnosed with toenail fungus infection?
Are you currently Pregnant or Breast-feeding?
Do you have a history of immunosuppression or a compromised immune system?
Are you currently using a steroid inhaler on a regular basis or are you currently using topical corticosteroid creams on a regular basis?
Are you currently being treated for cancer?
Have you ever had any type of transplant such as kidney, lung, heart or bone marrow?
Do you have diabetes or diabetic neuropathy?
Do you have AIDS or a positive HIV test?
Are you currently taking oral antifungal treatment for nail fungus infection?
Are you currently using any topical antifungal treatment for nail fungus infection?
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 & Past Medical History
Do you have or have you every 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?

Nail Fungus Infection History
Have you diagnosed with toenail fungus infection in the past by a physician in the past?
Have you been treated for a nail fungus infection in the past?
Do you have a family history of nail fungal infections?
Please check all that apply:

Personal and Payment Information
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

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, 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.
First, Choose REGULAR or 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, Regular Service your prescription is Eprescribed directly to your local pharmacy.) Processing fee $10.35

EXPRESS 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

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.

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.
2. Next, select Kerydin bottle size: *

2. Next choose Kerydin bottle size either 10ml or 4ml bottle:

Kerydin bottles come in 10ml and 4ml size.  Once opened the bottle should be discarded in 3 months.   If you have many nails infected, you should choose a 10ml bottle.  If you only have couple of nails infected, you may want to choose the 4ml bottle
  • I am am an adult 18 years of age or older.  
  • I have read and agree to Waiver of Liability.  
  • I understand that Kerydin Topical Solution is to be used EXTERNALLY only and only to be applied to the affected toenails and immediately adjacent skin.  Kerydin is NOT to be used on fingernail fungal infections. Kerydin is NOT to be used in the eyes, nose, mouth or vaginal area. 
  • I understand that pregnant and nursing mothers should NOT use Kerydin. 
  • 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 Kerydin.  
  • I understand that Kerydin Topical Solution 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 Kerydin  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 $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 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.
Please CONFIRM your selection made above of Regular or Express Service: *

If you selected EXPRESS Service or if you are from CA, NY, MA, VT, RI, CT and IN please confirm pharmacy information below:

Click SUBMIT button (secure server) to order Kerydin Solution Consultation

For any questions and fastest reply contact us by

email at wellnessmd@medicalwellnesscenter.com

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