Vaniqa Consultation Form

Please take the necessary time to carefully and truthfully complete all applicable questions on the form.  Incomplete forms will not be submitted to our physicians for a consultation, as failure to provide the medical information required to render a professional opinion is prima facie grounds to deny a prescription. If you want to ask us any questions before filling the form you can e-mail us at inquiries@net-dr.com. You can also visit www.vaniqa.com for more information about Vaniqa.

 
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Personal Information
  Name (First and Last)
Address
No Post Office Box
City
State
Zip Code
Country
Phone
(Required)
E-mail Address
(Required)
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Current Information
Age
(Required)
Height
  (Required)
Weight
(Required)
Date Of Birth
(MM/DD/YY)
(Required)
Sex
Male     Female
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Credit Card Information
Credit Card
Name Of Credit Card Holder
(Required)
Credit Card Number
(Required) NO DASHES!
Credit Card CVV
What is CVV? Click Here
Expiration
(Required)
Billing Address
(Required)
City, State, Zip
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Quantity of Vaniqa
Quantity Of Vaniqa
(if approved)
(Required)
Shipping Method
Note...
If my responses indicate that my unwanted facial hair may be treatable with Vaniqa, I understand that Net-Dr International physicians have found Vaniqa to be an effective treatment.

If I am approved for Vaniqa, please bill my prescription on my credit card and send me my medication immediately.

Have you
been diagnosed with:
yes   no   atherosclerosis             
yes   no   heart attack                       
yes   no   ovarian tumors           
yes   no   endocrine disorders           
yes   no   diabetes                      
yes   no   stroke                                 
yes   no   skin cancer            
yes   no   kidney disease                   
yes   no   hypertension                
yes   no   spinal cord injury               
yes   no   cirrhosis of the liver     
yes   no   thyroid disease                  
yes   no   anxiety                           
yes   no   breast cancer                   
Medical History
Please list ALL medications you are now taking and please explain why you are taking them.

Are you taking any of these medications specifically?
  Are you taking Phenytoin (Dilantin)?   no yes
  Are you taking Minoxidil?    no yes
  Are you taking Anavar?  no yes
Are you taking Dizoxide?
 no yes
 
Are you taking Cyclosporin?   
 no yes
 
Are you taking Danazoll?       
 no yes

Please list all known allergies:

Are you being treated for other medical conditions at this time?  no   yes (please specify)

What is your past surgical history?

Are you currently taking steroids? Please explain why.

Specifically are you applying any topical medications to your face?

Are you currently pregnant or breast feeding?

Do you currently have inflammatory acne?

Do you have any skin conditions?

Have you ever been diagnosed with hirsutism (excessive facial hair)?

In what regions of your face do you feel the hair is most prominent? Please explain.

Do you feel that you have excessive hair in any other region?

Do any diseases/disorders run in your family?   no   yes (please specify)

How much do you drink:  none   not much  moderately  heavily

Do you smoke? no  yes  packs per day 

Do you consider anything else in your medical history to be relevent?  no   yes (please specify)

Do you have any other questions?

Please give a description of your current condition?

What other methods are you currently using to remove excess hair?

How often do you remove unwanted hair?
By submitting this form, I certify that:
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I have read and agree to the Net Doctor International's waiver of liability.
True   False
I am permitted to receive the medication I requested in the state/region/country indicated as the shipping address:
True   False
I have provided truthful information to the best of my knowledge to Net Doctor International.
True   False
 Submit :
Note to US patients: In many cases, a Net Doctor International physician shall prefer to speak on the telephone briefly with patients prior to reaching a final decision. Please provide a telephone number (if different than above) where you may be reached and a convenient time in the 48 hours or sooner following the submission of your form. If you are not available at the time that the physician phones you, no message will be left, and if someone other than the patient answers the phone no details about the nature of the call or the caller will be disclosed. The physician will try to phone you on the following day at the same time, and if you still cannot be reached, we will contact you via e-mail.

Phone number ( if different from the above ) :

Convenient time to call:

Where did you find us?

By submitting this form you are agreeing to pay a $50 consultation fee. If you are not approved for a prescription, you will not be charged.

 


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