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 RENOVA for TOPICAL us only and is to be used as part of a comprehensive skin care program and is NOT to be used on any other parts of the body than the face.
I understand that pregnant and nursing mothers should NOT use RENOVA, and I agree not to use RENOVA is I am trying to get pregnant.
I am aware that RENOVA 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. RENOVA is NEVER to be used on sunburned skin
I understand that RENOVA 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 am using RENOVA. I also understand that I am not to use any facial products that may be drying or irritating to the skin while using RENOVA.
I do not have any of the contraindications to therapy, I do not have eczema 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 RENOVA or Retin-A from another physician.
I understand that my credit card will be billed $75.00 and $9.50 Regular or $20 Express 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 $75.00 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. I understand that I will receive a written prescription for RENOVA (tretinoin) cream with 11 refills valid in any major local United States pharmacy of my choice.
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.

Renova (tretinoin) REFILL Consult Form