Eucrisa REFILL Consultation Form
Eucrisa prescription for eczema / atopic dermatitis online consultWelcome back. After your initial consultation and Eucrisa Ointment prescription approval each follow-up consultation, if approved, is only $75.00 and  receive 12 refills of Eucrisa Ointment.  You must include your Medical Wellness Center Membership Number which was assigned upon approval into the program. If you don't have this available, you can Email us for your membership number.) If the consulting physician determines that Eucrisa refills are not appropriate for you,  there is NO charge for this consultation.  Available only in the United States.


Not available in Illinois and Arkansas or 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 CONTRAINDICATIONS, 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 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:YES NO 

     Available in the United States Only.
The medical information you supply is subject to ALL patient/doctor privilege laws.
MEDICAL HISTORY
First and Last Name: 
Medical Wellness Center Membership Number:

SEX:  FemaleMale 
Date of Birth(MM/DD/YY):          Current Age: 

Height (inches):                   Weight: 
Please describe the effect Eucrisa Ointment had for you:
Did you experience any side effects:  YES NO
If yes, have these symptoms resolved? YES NO
If yes, please describe symptoms:
Have there been any changes in your current medical conditions that the consulting Physician should be aware of?
(If yes, be sure to also consult you regular primary care physician, symptoms could be unrelated to current treatment and related to some other condition)

You can now choose one of the following choices:
  1. To receive a written prescription and fill your prescription at any local brick and mortar United States pharmacy of your choice 
  2. or have your prescription called into most any your  local United States pharmacy of your choice 

Check one ONE of the two choices below - written prescription or prescription called into pharmacy:
Check here if you choose to receive a written prescription  by mail  which you can fill at most any local U.S. pharmacy of your choice.  

Check here if you choose to have your prescription for a year of refills called into the pharmacy  rather than receiving a prescription by mail. If approved, your prescription will be called into any local United States pharmacy of your choice There is no extra charge for this service for refill prescriptions and your credit card will be billed the $75 consultation fee and regular S & H processing fee of $ 9.50 or $20 Express Service fee. If you are requesting your prescription to be called into your pharmacy, please enter the complete phone# including area code, name and address of pharmacy where you choose to fill your prescription. 
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 pimecrolimus, the active ingredient in Eucrisa Ointment  or any inactive components:benzyl alcohol, cetyl alcohol, citric acid, mono- and di-glycerides, oleyl alcohol, propylene glycol, sodium cetostearyl sulphate, sodium hydroxide, stearyl alcohol, triglycerides and water? 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, UVA/UVB phototreatment 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
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.

For refill prescriptions you have the option of:

1.  Receiving a WRITTEN prescription by mail which you can fill at most any local United States pharmacy of your choice (approximately 7- 15 days)

2.  Have your prescription called into your local U.S. pharmacy or faxed to Murray Avenue Apothecary at NO EXTRA charge in 3 - 7 days, COMPLEMENTARY call in service.

If you select option # 2, you can also select EXPRESS 24 hour processing where your prescription will be called into your local pharmacy or faxed to Murray Avenue Apothecary in approximately 24 hours.  If you select EXPRESS 24 hour processing you will be charged a $20 express processing service fee rather than the regular processing fee of $9.50. 
Please check here if your are selecting EXPRESS 24 hours service - $20 express processing fee


Check only ONE of the three choices 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.

2. Prescription called into your local pharmacy:
Prescription for one year of  refills called into any major local United States pharmacy of your choice rather than receiving a written prescription by mail. If approved, your prescription will be called into a pharmacy of your choice. There is no extra charge for this service for refill prescriptions  (unless you are choosing the Express Refill call in service) and your credit card will be billed the $75 consultation fee and regular S & H processing fee of $ 9.50. If you are requesting your prescription to be called into your pharmacy, please 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 brick and mortar 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 or Costco.com etc.) 

3. Prescription faxed to Murray Avenue Apothecary:
Choose to have your prescription faxed to either Murray Avenue Apothecary  and have the medication mailed directly to you.   If you select this choice you then must select below whether you want Murray Ave Apothecary.

Only if you selected to have your prescription faxed to and filled by Murray Avenue Apothecary please select this choice below: (It is imperative that you check first with the pharmacies on pricing of the medication. Medical Wellness Center only bills you for the consultation fee and the pharmacy you select will bill you directly for the medication itself. 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.)

Murray Avenue Apothecary:    412-421-4996
Please check here authorizing Murray Avenue Apothecary to fill your prescription, and your prescription will be forwarded to Murray Avenue Apothecary. 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 ($75.00 + 9.50 S & H or $20 if selecting express service. You need to call the pharmacy directly for pricing

If you are choosing to have your prescription called into your local pharmacy or faxed to Murray Ave Apothecary, please select whether you want Regular service or Express service.

REGULAR SERVICE:  No extra charge, regular processing fee of $9.50:  Prescription called into your pharmacy or faxed to Murray Ave in 3-7 days.
EXPRESS SERVICE:  $20 express processing fee  instead of the $9.50 regular processing fee- your prescription will be called into your local pharmacy or faxed to Murray Ave 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 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 $75.00 plus $9.50 S & H regular service or $20 Express service 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 $75.00 consultation and S& H  fees  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 I receive or decide  not to take the medication for any reason including the expense of the medication at the pharmacy or your insurance refuses cover. I understand that once I click SUBMIT button I can not cancel this consultation request for any reason.

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.

Please CONFIRM YOUR SELECTION made above of receiving written Rx or your Rx called into local U.S. pharmacy or receive your medication from Murray Avenue Apothecary:

Option 1 :  receive written prescription by mail in 7-15 days.
Option 2 : have prescription called into a local U.S. pharmacy. Please confirm pharmacy phone # below

Option 3 :Prescription faxed to Murray Avenue Apothecary
 
If you are choosing (option 2 or 3) to have your prescription called into your local pharmacy or faxed to Murray Ave Apothecary, please confirm your selection of whether you want regular service or Express service.
REGULAR SERVICE:  No extra charge 3 - 7 days :  Prescription called into your pharmacy or faxed to Murray Ave in 3-7 days- complementary.
EXPRESS SERVICE:  $20 express processing fee - your prescription will be called into your local pharmacy or faxed to Murray Ave  in approximately 24 hours or less.


Click SUBMIT button for Physician Consultation for Eucrisa Ointment
You may submit Consultation Form over the Internet (secure server) by clicking the SUBMIT button. 

For any questions & fastest reply contact us by

email at wellnessmd@medicalwellnesscenter.com
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