Soolantra Cream INITIAL Consult Form

Fields marked with an * are required

not available in Illinois and Arkansas

Please fill in all fields and respond to all questions honestly and completely so that a physician can review your consultation and prescribe Soolantra® cream if approved. If the consulting physician determines that Soolantra® cream 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

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 Soolantra® cream. Please be sure to read Soolantra® cream CONTRAINDICATIONS, WARNINGS and 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 and contraindications before filling out the medical consult form:

I have read the previous Soolantra® cream 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:

medical confidentiality

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

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Personal Details

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 medication?

If YES, please list all Prescription Medications you are currently taking:

The length of time taking each of them:

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

The length of time taking each of them:

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, trying to become 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 any prescription medications for rosacea?

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, Cleocin-T?

If yes, please list:

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 in addition to rosacea 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?

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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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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medical conditions

Current Medical Conditions & Past Medical History

Do you have or have you hever 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
Arenal 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 Diseases
Heart disease
Gallbladder disease
Stroke
Skin Cancer
Cancer
Diabetes
None of the Above

Are there any other diseases than run in your family?

Do any of your family members suffer from skin diseases?

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skin history

Rosacea Skin History

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

At what age did you first experience rosacea?

Have you been treated for rosacea in the past?

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

Do you have Ocular Rosacea?

If Yes, are you receiving physician monitoring for your Ocular Rosacea?

If yes, please describe how Rosacea affects your eyes and medical treatment:

Are you currently on any treatment regimen for you Rosacea -both over the counter and prescription products?

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

Please describe your rosacea condition. Describe areas of the body affected and severity. How long you've suffered with rosacea? Are the rosacea flare-ups decreasing or increasing in frequency and severity?.

Please describe what triggers your rosacea flare-ups:

Please describe what your daily skin care regimen is:

Do you have a family history of rosacea?

If yes, please explain:

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payment

Personal and Payment Information

payment Copy

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: *

Email Address: *

Name of Credit Card Holder

Credit Card Type

Credit Card Number: *

Expiration Date (credit card) *

Card Verification Value (CVV) - 3 Digit Security Code *

Billing Address:

Billing Zip Code:

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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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 mail order pharmacy such as Amazon.com or .COM pharmacy, 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.

Choose REGULAR or EXPRESS Service: *

REGULAR Service
EXPRESS Service

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 and fill. (For CA, NY, MA, VT, RI, CT and IN, Regular Service your prescription is Eprescribed directly to your 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, enter 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.

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By submitting this consultation form, I certify: *

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.

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InitialConsult-FINAL-CONFIRM-SELECTIONS *

REGULAR SERVICE: receive written prescription by mail in 7-15 days
REGULAR SERVICE for CA, NY, MA, VT, RI, CT and IN pharmacies only: ePRESCRIBED in 3-7 business days
EXPRESS SERVICE: prescription called into a local U.S. pharmacy within approximately 24

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Click SUBMIT button (secure server) to order Soolantra 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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