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 include redness, peeling, stinging, or a feeling of warmth which may go away during course of treatment. If you experience Blistering, Crusting, Swelling, Excessive redness or peeling of your skin CHECK WITH YOUR DOCTOR AS SOON AS POSSIBLE!
I understand that Differin® is for TOPICAL use only. Avoid eyes, angles of the nose, mucous membranes.
I understand that pregnant and nursing mothers should NOT use Differin®, and I agree not to use Differin® if I am trying to get pregnant.
I am aware that Differin® increases sensitivity to sun and I agree to limit exposure to the sun, use SUNBLOCK daily and I agree NOT to use Tanning Beds or sunlamps of any sort. Differin® is NEVER to be used on sunburned skin
I understand that Differin® must be STOPPED for 3 - 4 weeks prior to any irritating skin procedures such as Electrolysis, Hair Depilatories, Waxes, Peels or laser or plastic surgery.
I understand that I am NOT to use Benzoyl Peroxide on my face at the same time I using Differin®. I understand not to use alpha hydroxy, hydroxy or glycolic containing products. I also understand that I am not to use any facial products that may be drying or irritating to the skin while using Differin®..
I understand that I am NOT to use any topical products containing sulfur, resorcinol or salicylic acid while using Differin®.
I understand that I am NOT to use any abrasive soaps, astringents, alcohol-containing skin products on my skin while using Differin®.
I understand that I am NOT to use any oil-based cosmetics or moisturizers. All cosmetics and moisturizers must be noncomedogenic or nonacnegenic.
I do not have any of the contraindications to therapy, I do not have eczema, sebborheic dermatitis or any chronic skin condition, and I have read and understand the contraindications and possible side effects
I do not have a current prescription for Retin A or Renova..
I do not have a current prescription for Differin® from another physician.
I understand that my credit card will be billed $49.95 and $10.35 S & H processing fees 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 submitted, my request for a physician consultation can not be canceled.
Please check here if you are requesting our EXPRESS (available in United States only) review and processing of your medical evaluation. If approved your prescription will be called into a local pharmacy of your choice within 24 hours. We do not call in prescriptions to any internet pharmacies such as Drugstore.com etc.
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.