I am an adult 18 years of age or older.
I have read and agree to Waiver of Liability.
I have read and understand the side effects of this medication.
I understand that pregnant and nursing mothers should NOT use Soolantra® Cream, and I agree not to use Soolantra® Cream if I am trying to get pregnant.
I am not pregnant.
I am not currently breast feeding. I am aware that Soolantra® Cream (ivermectin) gets into breast milk.
I do not have any of the contraindications to therapy.
I do not have a current prescription for Ivermectin from another physician.
I understand that my credit card will be billed $49.95 (plus S&P $10.35 or $20 Express processing) for the medical consultation if approved, if not approved there is no charge for the consultation. I understand that by submitting this form it's an "electronic signature" of a binding agreement that I agree to pay the $49.95 consultation fee plus S & P 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 or take the medication or I am advised not to take this medication by another physician. I understand that whether I choose to fill the prescription or not or whether I change my mind and decide not to take the medication, there are absolutely NO refunds for the online consultation fee. It is YOUR responsibility to make sure the pharmacy you list can provide you with the medication. Also, if a pharmacy refuses to fill a valid prescription issued by Medical Wellness Center due to do failure to verify your billing, shipping, & or Credit card information that you provided to the pharmacy or failure of your payment authorization to them we do NOT refund the consultation fee.
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.