Before Proceeding
to the Medical Consultation Form
please read
CONTRAINDICATIONS
/PRECAUTIONS and WARNINGS
and accept the Waiver
of Liability
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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 contraindications, risks and side effects associated
with Aczone™ Gel prescription |
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CONTRAINDICATIONS
Aczone™ Gel
is the first FDA-approved new topical acne medication containing the exclusive
active ingredient, Dapsone. Aczone™ Gel use is CONTRAINDICATED
and must NOT be used in anyone with the following conditions:
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Do NOT use
Aczone™ Gel if you are pregnant or attempting to become pregnant.
Aczone™ Gel may cause fetal changes?
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Do NOT use
Aczone™ Gel if you are breast feeding.
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Do NOT use
Aczone™ Gel if you have Glucose-6-phosphate dehydrogenase (G6PD) deficiency.
Oral dapsone has produced dose-related hemolysis and hemolytic anemia.
Topical Aczone is not expected to increase dapsone in the blood to cause
clinical symptoms of hemolysis, but if you get any symptoms such as sudden
onset of back pain, breathlessness, tiredness/weakness, dark-brown urine,
high fever, or yellow/pale skin contact your doctor or emergency room immediately.
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Do NOT use
Aczone™ Gel if you are allergic or sensitive to dapsone or
any of the ingredients in Aczone.

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Aczone™ Gel
is contraindicated to be administered without direct dermatologist supervision
if you have severe case of acne Grade IV with pustules and cysts.
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Do NOT use
Aczone™ Gel if you have eczema, sebhoreic dermatitis or psoriasis skin
conditions.
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Do NOT use
Aczone™ Gel on broken or cut skin or sunburned skin.
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Do NOT use
Aczone™ Gel if you are being treated with Benzoyl peroxide products.
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Do NOT use
Aczone™ Gel if you are taking Trimethoprim-Sulfomethoxazole.
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Aczone™ Gel
is NOT approved for pediatric use for children under 12. We do NOT prescribe
Aczone™ Gel to anyone under the age of 18.
IMPORTANT
PRECAUTIONS and WARNINGS
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Aczone™ Gel
is ONLY approved for external TOPICAL use on the face, neck, chest, upper
back and shoulders and trunk. Avoid contact with eyes, lips, angles of
the nose and mucous membranes. Flush with water and seek medical
attention!
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Do NOT use
medicated soaps or abrasive cleansers. Use mild, non-soap, fragrance
free cleansers like Cetaphil® Cleansing Bars or Cetaphil® Gentle
Skin Cleanser.
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Do NOT combine
Aczone™ Gel with benzoyl peroxide product.
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Do NOT use
Aczone™ Gel with any acohol-containing products, astringents, witch hazel
or lime that may be drying to your skin.
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Do NOT have
any cosmetic peels, glycolic peels or laser procedures while using Aczone™
Gel.
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Do NOT use
Aczone™ Gel with any alpha hydroxy, hydroxy or glycolic acid products.
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Do NOT use
any oil-based cosmetics or oil-based moisturizers. Make sure all
cosmetics and moisturizer you use are noncomedogenic or nonacnegenic.
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Do Not use
Aczone™ Gel with any skin products containing sulfur, resorcinol or salicylic
acid.
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Do NOT use
Aczone™ Gel with any skin products containing benzoyl peroxide, Skinoren
or Azelex as they may be drying or irritating.
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Avoid waxing
or other depilatory methods on Aczone™ Gel treated skin.
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If you experience
skin irritation that is severe with blistering and crusting DISCONTINUE
USE and seek immediate medical attention from your regular physician.
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If you do not
see any improvement or your condition continues to worsen after 12 weeks
of treatment, discontinue use and see your own physician for evaluation
and treatment.
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Aczone™ Gel
is to be used as part of a skin care regimen and needs to be used continuously
to prevent acne outbreaks and scarring
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Keep away from
children.
IMPORTANT SAFETY INFORMATION
Aczone™
Gel is indicated for the topical treatment of acne vulgaris in patients
12 years and older. Apply to affected skin twice daily, avoiding
the eyes, lips and mucous membranes. The most common adverse events
associated with the use of Aczone™ Gel are redness, scaling, dryness,
oiliness and peeling. These side effects typically resolve
during the first four weeks of treatment, but speak to your doctor if they
persist. Do not use irritating topical products that
contain resorcinol, salicylic acid or sulfur when using Aczone™ Gel.
Aczone™ Gel has not been tested in pregnant or nursing women, or with elderly.
Pregnancy Category C. For safety do NOT use if pregnant or nursing.
IMPORTANT
PATIENT INSTRUCTIONS
How to apply Aczone™
Gel Gel 0.1%/2.5% - Easy to Use:
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Step 1: Wash.
Use in in the morning and right before bedtime. Gently cleanse the entire
face and acne areas with a mild non-soap cleanser such as Cetaphil®.
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Step 2: Dry.
Pat skin dry gently with a soft towel to remove excess water. Never
rub harshly, as this may irritate the skin.
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Step 3:
Apply a pea-size amount of Aczone™ Gel gel to your face and other acne
areas. Spread a thin film over the entire face avoiding the eyes,
lips, angles of the nose and mucous membranes. You may be tempted
to use more than a dot, thinking it will work faster or better on your
acne. Don't Too much will not work better but may increase the potential
for irritation.
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Apply Aczone™
Gel only twice a day in the morning and before bedtime
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It's WORTH
THE WAIT: By treatment week 8 - 12 you should start to see improvement
in your acne. If you do not see any improvement by week 12, discontinue
use and see your own doctor.
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Aczone™ Gel
must be used consistently in order to prevent and control acne outbreaks.
ADVERSE REACTIONS
- SIDE EFFECTS of TOPICAL ACZONE (dapsone) Gel 5%:
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The majority
of patients using Aczone™ Gel experience minimal side effects. Some
patients experience erythema (redness), drying, oiliness and peeling.
These side effects usually abate during continued use, an all side effects
are reversible when the treatment is discontinued or reduced. If
you experience increasing redness, swelling, blistering or crusting, stop
use of Aczone™ Gel and contact your doctor.
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If you get
the medication in your eyes, rinse immediately with water and contact your
regular physician!
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There are NO
systemic effects when used appropriately
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How
To Request a Aczone™ Gel PHYSICIAN CONSULT:
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First read
about Aczone™ Gel Gel and learn more about its indications and 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 Aczone™ Gel prescription with 2 refills which
can be filled at any local United States pharmacy of your choice. No medication
purchase required- you can choose any pharmacy where your medical insurance
accepted.
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This prescription
will provide a minimum of three months of therapy after which another medical
consultation is necessary to determine if your response to Aczone™ Gel
and whether you should continue on therapy. If Aczone™ Gel is working
for you, you will be prescribed Aczone™ Gel with 6 refills on each follow-up
medical consultation.
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This physician
evaluation is RISK-FREE. If Aczone™ Gel prescription is not appropriate
for you there is No charge. The initial consultation fee for the
physician evaluation is only $49.95.
We offer
Express service option: Your prescription is called into any local
United States pharmacy of your choice within approximately 24 hours or
less.
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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, precautions and warnings and
honestly acknowledge that you do not have any of the above contraindications
to Aczone™ Gel therapy. Also, that I
am aware of the side effects ! I fully understand that Aczone™
Gel is prescribed for Grade I - Grade III acne. Aczone™
Gel is contraindicated in anyone who is hypersensitive to dapsone
or any of its components, has eczema, seborrhea dermatitis, psoriasis,
has G6PD deficiency, or is under age 18. I understand that it is
solely my responsibility to seek diagnostic and medical treatment for any
underlying medical conditions from my own regular primary care physician. |
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