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Before
Proceeding to the Medical Consultation Form please read
CONTRAINDICATIONS
and WARNINGS
and accept
the Waiver of Liability
In order for Medical Wellness
Center Physicians to provide you with the best care you need read
and agree to Waiver of Liability and you need to reply honesty to
all questions and you need to understand any and all risks and side effects
associated with Valtrex
To order VALTREX Rx:
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First read about Valtrex and it's contraindications,
and read and agree to the Waiver of Liability
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Next, accurately and truthfully complete
and submit a medical consultation questionnaire
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Your medial consultation will be reviewed
by one of our Physicians and if approved you will receive a Valtrex prescription
valid for 6 months of treatment without any further consultation fees.
This physician evaluation is RISK-FREE. If Valtrex is not appropriate
for you there is No charge. The initial consultation fee for the
physician evaluation is only $49.95. If you desire to continue on
Valtrex suppressvie therapy, after the initial consultation, your refill
medical consultation if approved will be valid for an entire year ( 12
refills).
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If you you are experiencing an acute
herpes outbreak and need a prescription within 24 hours, you can indicate
this urgency and have your medical consultation reviewed and a prescription
called in to a pharmacy of your choice within 24 hours.
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CONTRAINDICATIONS:
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Anyone with any renal function abnormalities,
renal failure, renal disease, on dialysis, or any other medical disorder
of kidney function or any liver disease including but not limited
to cirrhosis of the liver, liver cancer, jaundice etc. should not
take Valtrex. If you have any questions about your medical condition,
consult your primary care physician before taking Valtrex.
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Hypersensitivity to any ingredient of
Valtrex: valacyclovir or acyclovir or Zovirax
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Absolutely no one under the age of 18
should take Valtrex
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Absolutely no one who has had an organ
transplant, a kidney transplant or a bone marrow transplant should take
Valtrex.
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Absolutely no one with advanced HIV
disease should take Valtrex.
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Pregnant women and nursing mothers should
NOT take Valtrex, there are no adequate studies to guarantee safety, and
acyclovir may get into breast milk.
IMPORTANT
WARNING:
Valtrex is approved
for the treatment of acute outbreaks of genital herpes and for suppressive
treatment to prevent recurrent outbreaks in ADULTS with NORMAL immune systems
only!
There are
no adequate studies of Valtrex during pregnancy, therefore Valtrex should
not be used by pregnant women. Also, genital herpes can cause complications
during pregnancy therefore your physician must be informed. Once
infected, the herpes virus stays in your body forever.
IMPORTANT
INFORMATION:
Valtrex is not
a cure for genital herpes and transmission of infection to others can occur
during asymptomatic viral shedding even when there are no lesions present
and even on continuous suppressive treatment with Valtrex. Valtrex
does not alter the need for protection during sexual contact. |
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I
DO NOT HAVE ANY OF THE ABOVE CONTRAINDICATIONS:
By accepting "I Agree" means
that you have read the above contraindication and warnings and honestly
acknowledge that you do not have any of the above contraindications to
Valtrex therapy. Also, that I am aware that I may still be infectious
even if taking Valtrex and asymptomatic. |
 
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Medical
Wellness Center
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