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 and adverse effect.
I understand that no one under age 18 should use Topical Acyclovir unless directly prescribed by monitoring pediatrician. I understand if I have advanced HIV disease, compromised immune system, or have had any organ transplant I can not use Topical Acyclovir.
I understand that pregnant and nursing mothers should not use Topical Acyclovir because there are not sufficient studies. I understand that pregnant, potentially pregnant or nursing women should not use Topical Acyclovir .
I am aware that in order to be eligible to receive a prescription, I must have been positively diagnosed to suffer from recurrent genital herpes or cold sores, and I need to inform my doctor that I am using Topical Acyclovir.
I do not have any of the contraindications to therapy.
I do not have a current prescription for Topical Acyclovir from another physician, and I will not combine this genital herpes/cold sore treatment with any other topical genital herpes or cold sore treatments including Denavir.
I understand that my credit card will be billed $49.95 and $10.35 regular processing or $20 express processing for the medical consultation if approved (no refunds for this consultation service), if not approved there is no charge. I understand that by submitting this form I agree to pay the $49.95 consultation plus processing fee 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 not to take the medication for any reason. I understand that once I submit my consultation for review there are absolutely NO cancellations or no refunds.
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. Once submitting this consultation I can not receive a credit for the consultation service if I for any reason change my mind and no longer desire a prescriptions, or if I decide not to fill the prescription , or longer choose to use the medication.

Topical Acyclovir Form