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 Differin® Gel 0.1% and Differin® Cream 0.1%. |
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CONTRAINDICATIONS
Differin®
is the first new topical retinoid treatment for specifically designed acne
and it's gentle one the skin. Differin® use is CONTRAINDICATED
and must NOT be used in anyone with the following conditions:
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Do NOT use
Differin® if you are pregnant or attempting to become pregnant.
Differin® (adapalene) has been show to cause fetal changes in animal
studies
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Do NOT use
Differin® if you are breast feeding.
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Do NOT use
Differin® if you are allergic or sensitive to Adapalene
any of the ingredients: Differin® Gel contains carbomer 980, propylene
glycol, poloxamer, disodium edetate, methyl hydroxybenzoate, phenoxyethanol,
sodium hydroxide and purified water. Differin® Cream contains carbomer
934P, cyclomethicone, edetate disodium, glycerin, methyl glucose sesquistearate,
methylparaben, PEG-20 methyl glucose sesquistearate, phenoxyethanol, propylparaben,
purified water, squalane, and trolamine.

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Differin®
is contraindicated if you have severe case of acne Grade IV with pustules
and cysts.
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Do NOT use
Differin® if you have eczema, sebbhoreic dermatitis or psoriasis skin
conditions.
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Do NOT use
Differin® on broken or cut skin or sunburned skin.
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Do NOT use
Differin® if you are being treated with Accutane, Retin-A, Retin-A
Micro, Tretinoin, isotretinoin preparation or other Vitamin a retinoid
products.
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Differin®
is NOT approved for pediatric use for children under 12. We do NOT prescribe
Differin® to anyone under the age of 18.
IMPORTANT
PRECAUTIONS and WARNINGS
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Differin®
is ONLY approved for external TOPICAL use on the face, neck, chest, upper
back and shoulders. Avoid contact with eyes, lips, angels of the nose and
mucous membranes. Flush with water and seek medical attention!
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Differin®
makes you more sensitive to sunlight. Avoid all sun exposure, including
tanning beds and sunlamps. Always use sunscreen and protective
clothing over treated areas.
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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
Differin® with any other retinoid, retinoic acid, trenitoin, or Vitamin
a product such as Renova, Retin-A, Retinol etc.
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Do NOT use
Differin® 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 Differin®.
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Do NOT use
Differin® 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
Differin® with any skin products containing sulfur, resorcinol or salicylic
acid.
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Do NOT use
Differin® 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 Differin® treated skin.
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Avoid exposure
to cold and windy weather which map be irritating to patients under treatment.
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If the you
are experiencing skin irritation you may try decreasing the frequency of
application until you can tolerate a once daily application. If the
skin irritation 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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Differin®
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
PATIENT INSTRUCTIONS
How to apply Differin®
Gel 0.1% or Differin® Cream 0.1% - Easy to Use:
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Step 1: Wash.
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 Differin® gel or Differin® cream 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 Differin®
only once a day before bedtime
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About 20% of
patients feeling a burning or tingling sensation immediately after application.
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Between 10
-40% of patients experience some drying, stinging, burning etc, but if
you experience a severe irritation decrease frequency of use until you
can build up a tolerance. If you experience blistering or crusting
discontinue use and seek medical attention from your own physician.
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It's WORTH
THE WAIT: During the first 2 weeks of treatment you may see an increase
in acne, but 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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Differin®
must be used consistently in order to prevent and control acne outbreaks.
Use it even after your acne goes away on areas where you usually have acne
outbreaks.
ADVERSE REACTIONS
- SIDE EFFECTS:
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The majority
of patients using Differin® experience minimal side effects.
Between 10 -40% of patients experience erythema (redness), drying, scaling,
irritation, pruritis (itching), burning, stinging and acne flare-ups.
About 20% of patients experience a feeling of stinging, pruritis or burning
immediately after application. 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 Differin® 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 DIFFERIN® PHYSICIAN CONSULT:
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First read
about Differin® Gel and Differin® Cream 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 Differin® prescription with 2 refills which
can be filled at any U.S. 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 Differin®
and whether you should continue on therapy. If Differin® is working
for you, you will be prescribed Differin® with 6 refills on each follow-up
medical consultation.
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This physician
evaluation is RISK-FREE. If Differin® 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 Differin® therapy. Also, that
I am aware of the side effects ! I fully understand that Differin®
is indicated only for Grade I - Grade III acne. Differin®
is contraindicated in anyone who is hypersensitive to adapalene or any
of its components, has eczema, sebborheic dermatitis, psoriasis 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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