Winlevi Acne Cream REFILL Form

Fields marked with an * are required

Welcome back.  After your initial consultation depending on your response to the first 12 weeks of therapy, you can receive a Winlevi® prescription with six refills.  If approved, the refill  consultation is only $75.00 plus processing.  There is no extra charge for your prescription to be called into any pharmacy of your choice unless selecting express service. Please fill in all fields and respond to all questions honestly and completely so that a physician can review your refill consultation and prescribe Winlevi®, if approved.  If the consulting physician determines that Winlevi® is no longer appropriate for you, there is NO charge for this consultation. Your Medical Wellness Center membership number assigned upon approval into the program is required.  (If you do not have this available, you can Email us for your membership number.) 

I have read the previous Winlevi® 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:

Available in the United States Only
 Not available in Arkansas, Illinois or Florida
The medical information you supply is subject to ALL patient/doctor privilege laws.

MEDICAL HISTORY

Sex

Did you experience any side effects:
If yes, have these symptoms resolved?
Have there been any changes in your current medical conditions that the consulting Physician should be aware of?

Do you take any prescription medication?
Do you have any known allergies to Medicines?
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?
Are you currently being treated with any Acne Prescription medications? *
Are you allergic to any creams or lotions or skin care products?
Do you have any pre-existing or chronic skin disorders such as but not limited to eczema, seborrheic dermatitis or psoriasis?
Is your skin very sensitive or frequently red or irritated?
Have you undergone Laser Resurfacing or facial laser or photo therapy or a Medically administered glycolic or chemical peel in the last 6 months?

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?
Are you currently being treated for cancer?

CURRENT MEDICAL CONDITIONS & PAST MEDICAL HISTORY

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

FAMILY HISTORY

Do any of your immediate family members have any of the following medical problems?

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?
Are you currently on any treatment regimen for you acne -both over the counter and prescription products? *
Do you have a family history of acne?

  • 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!


PERSONAL AND PAYMENT INFORMATION

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
Credit Card Verification:

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.)


AVAILABLE IN UNITED STATES ONLY 
Services not available in Arkansas, Illinois, or Florida 

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.

 Winlevi® is very expensive and there is a high probability it will NOT be covered by your insurance. A prior-authorization does not guarantee it will be covered.  Insurance companies want you to exhaust all less expensive alternatives.  Therefore it is imperative that you check with your pharmacy regarding costs.  There are NO refunds for the consult if you learn after that you cannot afford the medication.

1. First, check ONLY one of the two choice below: *

1. RECEIVE WRITTEN PRESCRIPTION: Receive Written prescription in approximately 7- 15 days which you can fill at most any local United States pharmacy of your choice. (not available for CA, NY, MA, VT, RI, CT and IN pharmacies)

2. PRESCRIPTION CALLED INTO LOCAL PHARMACY: Prescription for one year of refills called into most any local United States pharmacy of your choice rather than receiving a written prescription by mail. There is no extra charge for this service for refill prescriptions (unless you are choosing the Express Refill call in service). Your credit card will be billed the $75 consultation fee plus regular processing. If you are requesting your prescription to be called into your pharmacy, you will need to enter the complete phone# including area code, name and address of pharmacy where you choose to fill your prescription

The prescription can only be called into your local United States pharmacy. It can not be called in, faxed or filled at an internet pharmacy, foreign pharmacy, Canadian pharmacy or pharmacies such as Drugstore.com or Amazon.com or an internet version of a local pharmacy such as CVS.com or Costco.com etc. 
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.

2. Next, if you are choose REGULAR or EXPRESS Service: *

REGULAR SERVICE: No extra charge, regular processing fee of $9.50: Prescription called into your pharmacy or receive a written prescription in 7-15 days. (written prescription not available in CA, NY, MA, VT, RI, CT and IN)

EXPRESS SERVICE: $20 express processing fee instead of the $9.50 regular processing fee- your prescription will be called into your local pharmacy in approximately 24 hours.


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 Winlevi® is for TOPICAL use only. Avoid eyes, angles of the nose, mucous membranes.
  • I understand that pregnant and nursing mothers should NOT use Winlevi®, and I agree not to use Winlevi® if I am trying to get pregnant.
  • Winlevi® is NEVER to be used on skin with cuts, abrasions, eczema or sunburn.
  • I understand that I am not to use any facial products that may be drying or irritating to the skin while using Winlevi®.
  • I understand that I am NOT to use any abrasive soaps, astringents, alcohol-containing skin products on my skin while using Winlevi®.
  • 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 Winlevi®® from another physician. Medical Wellness Center does NOT fill prescriptions issued by other physicians nor do we sell or dispense medication.
  • I understand that my credit card will be billed $75.00 and $9.50 or $20 Express processing for the refill 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 $75.00 consultation if approved and understand that there are no refunds for any circumstances even if I later change my mind and decide not to take the medication for any reason. I understand that once I submit my consultation for review there are absolutely NO cancellations. I understand that I am not purchasing medication and can choose most major local United States pharmacy to fill the prescription. Prescriptions can not be filled at internet such as Amazon.com nor Costco.com, foreign or Canadian pharmacies.
  • 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.

REFILL Please CONFIRM YOUR SELECTION made above: *

Click SUBMIT button (secure server) to order Winlevi® Refill Consultation

For any questions and fastest reply contact us by

email at wellnessmd@medicalwellnesscenter.com

Phone (United States Only):  617-367-8887