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Before Proceeding to the Medical Consultation Form 
please read
and accept the Waiver of Liability
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%.
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:
  • 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
  • Do NOT use Differin® if you are breast feeding.
  • 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. Grade IV acne - Differin is NOT approved for Grade IV acne characterized by many pustules and deep cysts.
  • Differin® is contraindicated if you have severe case of acne Grade IV with pustules and cysts.
  • Do NOT use Differin® if you have eczema, sebbhoreic dermatitis or psoriasis skin conditions.
  • Do NOT use Differin® on broken or cut skin or sunburned skin. 
  • 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.
  • Differin® is NOT approved for pediatric use for children under 12. We do NOT prescribe Differin® to anyone under the age of 18.
    • 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!
    • 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.
    • Do NOT use medicated soaps or abrasive cleansers.  Use mild, non-soap, fragrance free cleansers like Cetaphil® Cleansing Bars or Cetaphil® Gentle Skin Cleanser.
    • Do NOT combine  Differin® with any other retinoid, retinoic acid, trenitoin, or Vitamin a product such as Renova, Retin-A, Retinol etc.
    • Do NOT use Differin® with any acohol-containing products, astringents, witch hazel or lime that may be drying to your skin.
    • Do NOT have any cosmetic peels, glycolic peels or laser procedures while using Differin®.
    • Do NOT use Differin® with any alpha hydroxy, hydroxy or glycolic acid products.
    • Do NOT use any oil-based cosmetics or oil-based moisturizers.  Make sure all cosmetics and moisturizer you use are noncomedogenic or nonacnegenic.
    • Do Not use Differin® with any skin products containing sulfur, resorcinol or salicylic acid.
    • Do NOT use Differin® with any skin products containing benzoyl peroxide, Skinoren or Azelex as they may be drying or irritating.
    • Avoid waxing or other depilatory methods on Differin® treated skin.
    • Avoid exposure to cold and windy weather which map be irritating to patients under treatment.
    • 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.
    • 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.
    • Differin® is to be used as part of a skin care regimen and needs to be used continuously to prevent acne outbreaks and scarring
    • Keep away from children.


How to apply Differin® Gel 0.1% or Differin® Cream 0.1% - Easy to Use:
  1. Step 1: Wash.  Right before bedtime, gently cleanse the entire face and acne areas with a mild non-soap cleanser such as Cetaphil®.
  2. Step 2: Dry.  Pat skin dry gently with a soft towel to remove excess water.  Never rub harshly, as this may irritate the skin.
  3. 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.
  4. Apply Differin® only once a day before bedtime
  5. About 20% of patients feeling a burning or tingling sensation immediately after application.
  6. 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.
  7. 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.
  8. 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.


  • 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. 
  • If you get the medication in your eyes, rinse immediately with water and contact your regular physician! 
  • There are NO systemic effects when used appropriately

    1. 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.
    2. Next, accurately and truthfully complete and submit a medical consultation questionnaire
    3. 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. 
    4. 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.
    5. 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.

    6. We offer Express service option:  Your prescription is called into any local United States pharmacy of your choice within approximately 24 hours or less.
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.
I agree, proceed to DifferinŽ Waiver of LiabilityI disagree - DifferinŽ Contraindications


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