EUCRISA Medical Consultation Form
EUCRISSA prescription for eczema atopic dermatitis online consultPlease fill in all fields and respond to all questions honestly and completely so that a physician can review your consultation and prescribe Eucrisa ointment if approved. If the consulting physician determines that Eucrisa ois not appropriate for you, there is NO charge for this consultation. You choose to receive a written prescription by mail, Express 24 hour service to your local pharmacy, or have your Eucrisa omedication delivered to your door from the independent Murray Avenue Apothecary

Available only in the United States.
Not available in Illinois and Arkansas and Florida



In order for Medical Wellness Center 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 Eucrisa ointment.   Please be sure to read Eucrisa oCONTRAINDICATIONS, WARNINGS & 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 before filling out the medical consultation form: I have read the previous Eucrisa oPages 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:YES NO 
The medical information you supply is subject to ALL patient/doctor privilege laws.
MEDICAL HISTORY
First and Last Name: 
SEX:  FemaleMale 
Date of Birth(MM/DD/YY):          Current Age: 

Height (inches):                   Weight: 
Please list all current Medical Conditions:

Do you take any prescription medication?YESNO
If YES, please list all Prescription Medications you are currently taking and the length of time taking each of them: For example: Claritin -4yrs; Zoloft- 6mo, etc.

Please list all over-the-counter drugs you take regularly and why. 
For example: aspirin -for migraines, Unisom -difficulty sleeping etc.

Do you have any known allergies to Medicines?YES NO
If Yes, please list any known Allergies to Medicines:

 
Have you previously been diagnosed in the past to suffer from atopic dermatitis or eczemaYES  NO 
Are you currently Pregnant, trying to become pregnant or Breast-feeding? YES NO
Are you hypersensitive or allergic to the active ingredient, crisaborole, or to any component of Eucrisa ointment: white petrolatum, propylene glycol, mono- and di-glycerides, paraffin, butylated hydroxytoluene, and edetate calcium disodium? YES NO
Do you CURRENTLY have any INFECTED, weeping, oozy eczema lesions? YES NO
Have you ever had any type of transplant such as kidney, lung, heart or bone marrow?YES NO 
Do you have AIDS or a positive HIV test or have you recently been exposed to AIDS? YES NO
Are you allergic to any creams or lotions or skin care products? YES NO
If yes, please explain: 
Are you currently using any topical PRESCRIPTION medications on your body? YES NO
If yes, please explain and detail the areas of use and if it is on the area of the eczema lesions or a different area: 
Are you currently being treated for cancer?YES NO 
If yes, please explain: 
Have you had a physical exam in the last two years?YES  NO 
Do you smoke?YES NO
Do you consume more than 2 servings of alcohol per day? YES NO
CURRENT MEDICAL CONDITIONS & PAST MEDICAL HISTORY
Do you have or have you ever had any of the following conditions?
Asthma Allergies Hay Fever
Liver disease HIV Positive Kidney Disease
Leukemia Sickle Cell Anemia Organ Transplant
Skin Disease Eczema Sensitive Skin
Compromised ImmuneSystem Seizures Anxiety
Coronary Artery Disease Heart Disease Cancer
High Blood Pressure Stroke Diabetes
Thyroid disease Depression Endocrine Disorders
Are you currently taking steroids?YES NO
Have you had surgery in the last 3 months?
YES  NO 
If yes, please explain: 
Do you consider anything in your medical history to be relevant, please give details.
If unsure, please ask your regular doctor
FAMILY HISTORY:
Do any of your immediate family members have any of the following medical problems?
Diabetes Liver Disease Stroke
High blood pressure Heart disease Arteriosclerosis
Kidney Disease Gallbladder disease Cancer
Allergies Hay Fever Asthma
Eczema or Atopic Dermatitis Sensitive Skin Skin Disease
Are there any other diseases than run in your family? 
Are there any skin diseases than run in your family? 
 Eczema Atopic Dermatitis History
Have you diagnosed with eczema or atopic dermatitis by a physician in the past? Yes  No
Have you been treated for a eczema in the past?Yes  No
Please list types of treatment for eczema / atopic dermatitis  you've received:

 Please check all, if any, of these treatments you have received in the past for eczema: Topical  Steroids  UVA/UVB Phototherapy  Protopic Ointment or Elidel Cream   Antihistamines   Other
Are you currently on any treatments for your skin condition? Eucrisa ointment can NOT be used along with topical steroids or any other topical skin medication.  These treatments have to stop in order to use Eucrisa ointment :
 
At what age were you first diagnosed with Eczema or Atopic Dermatitis?
Please describe your eczema atopic dermatitis: describe appearance of lesions, size, color, location.  Describe how frequently you have flare ups.  And describe current condition of your skin -whether any or the eczema lesions are weeping, oozing, pus-filled... infected?.

PERSONAL and PAYMENT INFORMATION 
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(Required):
EMAIL(Required):
Please provide complete email, ie You@domain.com or name@aol.com 
NAME OF CREDIT CARD HOLDER
ENTER CREDIT CARD TYPE:
ENTER CREDIT CARD NUMBER
EXPIRATION DATE(MM/YY):
Enter you credit card 3 digit security number. To find this number turn your card around and on the back on the strip where you sign your name there are some numbers printed. There are either a set of 4 numbers (the last 4 numbers of your credit card) and a set of 3 numbers, or just a set of 3 numbers. The set of 3 numbers is the security number that is necessary in order to process your request.
ENTER 3 Digit Security Code
BILLING ADDRESS:
BILLING ZIP CODE
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.)YES NO
Please CONFIRM YOUR SELECTION made above of receiving written Rx, Express Service called into local U.S. pharmacy:   - 
Option 1 : Regular Service - receive written prescription by mail in 7-15 days
Option 2 : EXPRESS Service - have prescription called into a local U.S. pharmacy within approximately 24 hours
If you selected Express service, confirm the name and phone number of your Local United States Pharmacy below:
Option 3: Murray Avenue Apothecary ships you the medication to your home - Regular Service: consult reviewed and faxed to Murray Avenue Apothecary in 3 - 7 days
Option 4: Murray Avenue Apothecary ships you the medication to your home - Express Service: consult reviewed and faxed to Murray Avenue Apothecary in approximately 24 hours
 
AVAILABLE IN UNITED STATES ONLY 
Services not available in Arkansas, Illinois, or Florida 

You can choose to fill your prescription and your local United States pharmacy. 
In addition you can choose  either Regular or 24 hour Express Service:

 

You can choose to receive a written prescription and fill your prescription at most any local, brick and mortar, United States pharmacy of your choice or  EXPRESS service and have your prescription called into the local United States pharmacy of your choice.

Our prescriptions can only be filled at a local United States pharmacy of your choice, they can not be filled at internet or foreign or Canadian or internet versions of pharmacies.  If you would prefer to receive your medication by mail you can choose to have your prescription faxed to an approved local United States pharmacies that will mail your medication directly to you. The pharmacy will contact you and fill the prescription and mail the medication directly to you.  (Medical Wellness Center has no financial ties to these pharmacies.  They were chosen for their outstanding customer service, excellent compounding expertise, and reliability.  They only dispense 100% FDA approved manufactured medications.)
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.

1. First choose whether you want to fill you prescription at your local U.S. pharmacy or at Murray Avenue Apothecary.   Choose only ONE of these two choices.

Prescription filled at your local United States pharmacy:
Choose to fill prescription at your local pharmacy: Please check here if you are choosing to fill your prescription at your local United States pharmacy.  If you want to purchase your prescription from your local pharmacy, you then can select whether you want Regular service and wait 7-15 days to receive your written prescription by mail or whether you want Express service and your prescription is called into your local pharmacy in approximately 24 hours.  

Murray Avenue Apothecary: 412-421-4996
Murray Avenue Apothecary is a specialized compounding pharmacy. This pharmacy has excellent pricing, especially for medications that are not covered by insurance or for those who do not have insurance. Please check FIRST with the pharmacy in regards to pricing of the medication. Only if you are choosing to fill your prescription online and have  Murray Avenue Apothecary ship the medication to you check below:
Authorized Murray Avenue Apothecary to fill prescription: Please check here authorizing Murray Avenue Apothecary to fill your prescription. Your medication will be shipped directly to your shipping address that you provided to the pharmacy and you will be billed by Murray Avenue Apothecary for the medication . Medical Wellness Center will only bill you for the online consultation fee.

If you have any questions in regards to shipping status and tracking information you need to contact the pharmacy directly:   Murray Avenue Apothecary 412-421-4996.

2. Next after making this above selection then choose whether you want regular service (7-15 days) or Express 24 hour service.

REGULAR SERVICE:  Consult reviewed within approximately 3-7 business days and your 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 or your prescription is faxed to Murray Ave Apothecary in 3-7 days. Processing fee $10.35

EXPRESS SERVICE:  Consult reviewed and prescription within approximately 24 hours called into most any local United States pharmacy of your choice or faxed to Murray Avenue Apothecary. Express processing fee $20. Please check here if you are  requesting  our EXPRESS  review and processing of your  medical evaluation.  If approved  your prescription will be called into your  LOCAL United States  pharmacy of your choice within 24 hours.  If you checked yes and you are approved  you will be billed a $20 express processing fee.  IF YOU ARE REQUESTING EXPRESS SERVICE CALLED INTO A PHARMACY MAKE SURE YOU ENTER THE NAME, ADDRESS AND PHONE NUMBER OF YOUR LOCAL UNITED STATES PHARMACY BELOW
If you are requesting express service, please enter complete phone# including area code, name and address of pharmacy where you choose to fill your prescription.  If you are selecting Murray Avenue Apothecary just write in your choice, you do not need to include phone number.   The prescription can only be called into your local U.S. 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 an internet version of a local pharmacy such as CVS.com etc. 
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 most common side effects of this medication and adverse effect which are pain, burning or stinging at the application site. These symptoms usually resolve withing days.   Eucrisa can cause serious allergic reactions at or near the application site which may include hives, swelling, and redness. If you have any of these symptoms STOP using Eucrisa and get medical help right away.
I understand Eucrisa can cause serious allergic reactions at or near the application site which may include hives, swelling, and redness. If you have any of these symptoms STOP using Eucrisa and get medical help right away.
I understand that Eucrisa ointment is not to be used by anyone with infected, oozing eczema skin lesions.
I understand that pregnant, attempting to become pregnant and nursing mothers should NOT use Eucrisa Ointment. 
I am aware that in order to be eligible to receive a prescription, I must have been positively  diagnosed with eczema/ atopic dermatitis in the past, and I need to inform my doctor that I am using Eucrisa ointment. 
I do not have any of the contraindications to therapy and I have read and understand the contraindications and possible side effects. I understand that I must NOT  use Eucrisa ointment with any other topical skin products or topical prescriptions, except moisturizers and sunblock.
I do not have a current prescription for Eucrisa ointment from another physician. 
I understand that my credit card will be billed $49.95 plus $10.35 S & H or $20 Express  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 $49.95 consultation and S& H  fees  if approved, and I 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 including cost at the pharmacy or the insurance does not cover this medication. I understand that once I click SUBMIT button I can not cancel this consultation request for any reason.
Please check here if you are  requesting  our EXPRESS (available in United States only)  review  and processing of your medical evaluation.  If approved  your prescription will be called into a pharmacy of your choice within approximately 24 hours.  If you checked yes and you are approved  you will be billed a $20 express S & H processing fee. If  you are requesting express service, please enter phone#, name and address of pharmacy where you choose to fill your prescription. 

I certify that I  have answered all the questions truthfully.

Please CONFIRM YOUR SELECTION made above of receiving written Rx, Express Service called into local U.S. pharmacy: 
Option 1 : Regular Service - receive written prescription by mail in 7-15 days
Option 2 : EXPRESS Service - have prescription called into a local U.S. pharmacy within approximately 24 hours
If you selected Express service, confirm the name and phone number of your Local United States Pharmacy below:
Option 3: Murray Avenue Apothecary ships you the medication to your home - Regular Service: consult reviewed and faxed to Murray Avenue Apothecary in 3 - 7 days
Option 4: Murray Avenue Apothecary ships you the medication to your home - Express Service: consult reviewed and faxed to Murray Avenue Apothecary in approximately 24 hours



Click SUBMIT button for Physician Consultation for Eucrisa ointment
You may submit Consultation Form over the Internet (secure server) by clicking the SUBMIT button. 
Email to contact Medical Wellness CenterTo contact Medical Wellness Center -with any questions, please Email us.
 
PHONE  NUMBER:
(US ONLY)		 617-367-8887
ADDRESS: Medical Wellness Center
Marlborough, MA 01752