Differin INITIAL Consult Form

Fields marked with an * are required

before info

Please fill in all fields and respond to all questions honestly and completely so that a physician can review your consultation and prescribe Differin® if approved. If the consulting physician determines that Differin® is not appropriate for you, there is NO charge for this consultation.

Available in the United States Only.

Not available in Illinois and Arkansas and Florida

Differin® is available in a tube or pump formulation. Choose below whether you want a 45gm Differin 0.3% tube or pump

Differin 0.3% Formulations:

Differin Gel 0.3% 45gm Tube
Differin Gel 0.3% 45 gm Pump

Select your choice below:

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In order for Medical Wellness Center's 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 Differin®. Please be sure to read Differin® 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 conditions before filling out the medical consultation form:

I have read the previous Differin® 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: *

doctor privilege

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

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Medical History

First and Last Name: *

Date of Birth: *

Current Age

Sex

Height (inches):

Weight (pounds)

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Please list all current Medical Conditions:

Do you take any prescription medications?

If Yes, please list all Prescription Medications you are currently taking

Include Prescription Medications you are currently taking and the length of time taking each of them: For example: Claritin -4yrs; Zoloft- 6mo,etc.

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

For example: aspirin -for migraines, Unisom -difficulty sleeping etc.

Do you have any known allergies to Medicines?

If Yes, please list any known Allergies to Medicines:

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Are you currently Pregnant or Breast-feeding?

Are you currently trying to become pregnant?

Are you currently using any topical PRESCRIPTION medications on your face?

If yes, please explain:

Are you currently being treated with Accutane, Renova, Retin-A, Retin-A Micro, Tretinoin, Retinol, isotrentinoin or an other Vitamin A product?

If yes, please detail what medication you are using, how long and why you are using it?:

Are you currently using any topical antibiotic prescriptions such as erythromycin or clindamycin, Delacin-T, Celocin-T...?

If Yes, please list:

Are you currently using any skin products containing sulfur, resorcinol or salicylic acid?

If yes, please list products using:

Are you allergic to any creams or lotions or skin care products?

If yes, please explain:

Do you have any pre-existing or chronic skin disorders such as but not limited to eczema, seborrheic dermatitis or psoriasis?

If yes, please describe your condition, how long, severity and location:

Do you have very sensitive skin?

If yes, please how sensitive your skin is:

Is your skin frequently red or irritated?

If yes, please explain:

Are you extremely sensitive to the sun?

Have you undergone Laser Resurfacing or facial laser or photo therapy or a Medically administered glycolic or chemical peel in the last 6 months?

Please list any plastic surgery, laser or medical peels or cosmetic procedure you have had in your lifetime on your face and when these procedures were done:

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do you take the following

Do you currently take any of the following medication?

Benzoyl peroxide topicals like Pan Oxyl:

Topical Antibiotics - Cleocin-T, Dalacin-T, erythromycin or clindamycin?

Topical preparations containing sulfur, resorcinol or salicylic acid?

Renova?

Vaniqa Cream?

Accutane, Retin-A or Vitamin A skin cream?

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Have you had a physical exam in the last two years?

Are you currently taking steroids?

Do you smoke?

Do you consume more than 2 servings of alcohol per day?

Have you had surgery in the last 3 months?

If Yes, please explain:

Are you currently being treated for Cancer?

If yes, please explain:

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current medical conditions

Current Medical Conditions & Past Medical History

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

Kidney Disease
Eczema
Skin Cancer
Organ Transplant
Coronary Artery Disease
High Blood Pressure
Thyroid disease
Liver Disease
Skin Disease
Mental Illness
Seizures
Heart Attack
Stroke
Adrenal Disease
Sebborheic Dermatitis
Psoriasis
Depression
Anxiety
Heart disease
Diabetes
Endocrine Disorders
None of the Above

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?

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

Are there any other diseases than run in your family?

Do any of your family members suffer from acne?

If yes describe the relation and the severity of the acne:

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acne skin history

Acne Skin History

Have you diagnosed with acne in the past by a physician in the past?

Have you been treated for acne the past?

If yes, please list types of treatment for acne you've received in the past:

Are you CURRENTLY on any treatment regimen for you acne -both over the counter and prescription products? *

If yes, please list types of treatment for acne you are currently receiving:

Please describe what your daily skin care regimen is.

Do you have a family history of acne?

If yes, please explain:

At what age did you first experience acne?

Please describe your acne condition. Describe areas of the body affected and severity. *

How long you've suffered with acne? Are the outbreaks decreasing or increasing in severity?.

Click on image below to select acne Grade that best describes the extent of your acne condition: *

Grade 1
Grade 2
Grade 3
Grade 4

Grade I: Mostly comedians - blackheads and whiteheads
Grade II: Comedones, papules - blackheads, whiteheads & pimples
Grade III: Comedones, papules, pustules & few nodules
Grade IV: Comedones, papules, PUSTULES AND CYSTS!

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payment details

Personal and Payment Information

payment disclaimer

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 Number: *

Email Address: *

Name on Credit Card

Credit Card Type:

Credit Card Number: *

Expiration Date (credit card): *

Card Verification Value (CVV) 3 digit security code *

Billing Address:

Billing Zip Code:

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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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post form information

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: *

REGULAR Service
EXPRESS Service

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. (For Regular Service for CA, NY, MA, VT, RI, CT and IN, the prescription is Eprescribed to your local pharmacy.) Processing fee $10.35

EXPRESS SERVICE: Consult reviewed and prescription called 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.

Next, Choose Differin® (adapalene) comes in several formulations, confirm you selection. *

Differin® Gel 0.3% 45 gm Tube
Differin® 0.3% 45gm Pump

Next, choose the Differin 0.3% strength formulation:
We prescribe both Differin® Gel 0.3% in a 45 gm tube and a 45 gm Pump.

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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 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.

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Please CONFIRM YOUR SELECTION made above: *

REGULAR SERVICE: receive written prescription by mail in 7-15 days (not available in CA, NY, MA, VT, RI CT and IN)
REGULAR SERVICE for CA, NY, MA, VT, RI CT and IN pharmacies only: ePRESCRIBED in 3-7 business days
EXPRESS SERVICE: prescription called/ePrescribed into a local U.S. pharmacy within approximately 24

Confirm Pharmacy Information if selecting Express Service of are from CA, NY, MA, VT, RI, CT and IN:

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.

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Click SUBMIT button (secure server) to order Differin Initial 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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