AVODART REFILL   Medical Evaluation Form 
AvodartWelcome back. After your initial consultation and AVODART approval each follow-up consultation, if approved, is only $75 and includes Avodart refill prescriptions good for 12  months.  Hair growth is very slow and it may take up to a year to notice the full benefits.    After the first 3 months of treatment you may start to notice some improvement and for some improvements are not noticed until 6 months or longer.  Male pattern hair loss is a life-long condition and you need to continue to take Avodart to stop the natural progression of Male pattern baldness and to prevent the new hair regrowth from thinning out. Please accurately and completely provide the following information in order for a physician to review your record. You must include your Medical Wellness Center Membership Number which was assigned upon approval into the program. (If you don't have this available, you can Email us for your membership number.)
 

Generic Avodart = dutasteride 0.5mg now available 
CHOOSE:*****Check first with your pharmacy regarding pricing - we will NOT call a pharmacy to change to the generic if you later find out it is too expensive!  It is YOUR responsibility to check first with the pharmacy. There will be NO changes!

Brand Name Avodart -make sure you check with your pharmacy first for price difference between the brand name and the generic dutasteride equivalent.  If you select brand name Avodart, we can not later change it to generic dutasteride 0.5mg. 
GENERIC Avodart =dutasteride 0.5mg


HairSite is conducting a comprehensive survey on individuals using Avodart.
 Please click here and fill out the survey

 NOT  AVAILABLE IN ILLINOIS AND ARKANSAS AND FLORIDA

Please fill in all fields and respond to all questions honestly and completely so that a physician can review your consultation and prescribe Avodart if approved.   Do NOT combine Avodart and Propecia.   If the consulting physician determines that Avodart Refills are not appropriate for you, there is NO charge for this consultation.
Click here  to read the stated conditions before filling out the medical consultation form: I have read the previous Avodart pages and I do NOT have any of the stated contraindications. I understand the WARNINGS and I have read and agree to the Waiver of Liability:YES NO 
The medical information you supply is subject to ALL patient/doctor privilege laws.
MEDICAL HISTORY 
First and Last Name:

Medical Wellness Center Membership Number: 

SEX: Female  Male 
Date of Birth(MM/DD/YY):         Current Age: 
Height (inches):Weight:
  : 
Did you experience any sexual dysfunction or side effects:YES NO
If yes, have these symptoms resolved? YES NO
If yes, please describe symptoms:
Describe your response to Avodart treatment and detail the progress. Detail how long before you started to notice changes, if you had any initial shedding, thickening of hair, regrowth etc.
Have there been any changes in your current medical conditions that the consulting Physician should be aware of?
(If yes, be sure to also consult you regular primary care physician, symptoms could be unrelated to current treatment and related to some other condition)

Please list all current Medical Conditions:

  Do you currently use topical Minoxidil?YESNO
If Yes,what is the strength and additives in the formulation:

Do you take any prescription medication?YESNO
If YES, please list all Prescription Medications you are currently taking and the length of time taking each of them: For example: Claritin -4yrs; Zoloft- 6mo,etc.

Please list all over-the-counter drugs you take regularly and why. 
For example: aspirin -for migraines, Unisom -difficulty sleeping etc.

Do you have any known allergies to Medicines?YES NO
If Yes, please list any known Allergies to Medicines:

 Have you had a physical exam in the last two years?YES  NO 
 
Do you presently have liver disease, liver function abnormalities, hepatitis or any medical disorder of liver function including but not limited to cirrhosis of the liver, liver cancer, jaundice etcYES  NO 
Are allergic to Avodart, dutasteride, finasteride , Propecia or any of the ingredients in Avodart? YES NO
Are you currently taking  ORAL Nizoral (ketoconazole) or  Sporanox (itraconazole)?YES NO
Are you currently taking PROSCAR? YESNO
Do you have AIDS or a positive HIV test or have you recently been exposed to AIDS? YES NO
Are you currently taking Protease Inhibitors: Agenerase (amprenavir), Crixivan (indinavir), Viracept (nelfinavir), Norvir (ritonavir) or Invirase or Fortovase (saquinavir)?YES NO
Have you been diagnosed with prostate cancer? YES NO
Do you have BPH - benign prostatic hypertrophy ? YES NO
Are you currently being treated for cancer?YES NO 
If yes, please explain: 
Do you smoke?YES NO 

How much alcoholic beverages do you drink?
None  Occasionally  Moderately  Heavily 
CURRENT MEDICAL CONDITIONS & PAST MEDICAL HISTORY
Do you have or have you ever had any of the following conditions?
Chronic Malabsorption Syndrome gallbladder disease Liver Disease
Liver function abnormalities Cirrhosis of Liver Hepatitis
Jaundice Kidney Disease Prostate problems
Prostate cancer Enlarged Prostate Elevated PSA Levels
Coronary Artery Disease Heart Attack Heart disease
High Blood Pressure Stroke Diabetes
Thyroid disease Depression Endocrine Disorders
Are you currently taking steroids?YES NO
Are you currently being treated for cancer? 
YES NO 
If yes, please explain: 
Have you had surgery in the last 3 months? 
YES: NO 
If yes, please explain: 
Do you consider anything in your medical history to be relevant, please give details.
If unsure, please ask your regular doctor
FAMILY HISTORY:
Does Male Pattern Hair Loss run in your family?YES NO
Do any of your immediate family members have any of the following medical problems?
Diabetes Liver Disease Stroke
High blood pressure Heart disease Arteriosclerosis
Kidney Disease Gallbladder disease Cancer
Prostate Cancer Benign Prostate Enlargement Male Baldness
Are there any other diseases than run in your family?
HAIR LOSS HISTORY
Do you suffer from Male Pattern Baldness?Yes No
Have you been treated before for hair loss?Yes No
Check each treatment that you have undergone:Rogaine/minoxidil PropeciaSurgicalOther 
If other, please list
At what age did you first notice hair thinning?
Was your hair loss Sudden    or Gradual
Please describe your history of hair loss: 
Please from the illustration and description below, choose which Norwood Classification of Hair Loss best describes your present condition: 
Norwood Classification of Male Pattern Baldness - Avodart
Please select your current Norwood Classification:
Class 2: Receding HairlineClass 3: Generalized Frontal Thinning 
Class 4: Frontal Area & Crown Balding Class 5: Top of Scalp & Crown Balding 
Class 6: Extensive Hair LossClass 7: Severe Hair Loss Only rim of hair remains
PERSONAL and PAYMENT INFORMATION 
In order to review your consultation, you must provide your full name, a Physical Address (We do NOT accept requests to PO Boxes) and complete Phone number. We do NOT accept requests from Illinois or Arkansas or Florida
FULL NAME:
ADDRESS: (Physical Address Necessary
We do NOT process any orders to PO BOX#'s)
CITY:
STATE:     ZIP CODE 
COUNTRY:
PHONE (REQUIRED):
EMAIL: (REQUIRED)
Please provide complete email, ie You@domain.com or name@aol.com 
NAME OF CREDIT CARD HOLDER
ENTER CREDIT CARD TYPE:
ENTER CREDIT CARD NUMBER
EXPIRATION DATE(MM/YY):
Enter you credit card 3 digit security number. To find this number turn your card around and on the back on the strip where you sign your name there are some numbers printed. There are either a set of 4 numbers (the last 4 numbers of your credit card) and a set of 3 numbers, or just a set of 3 numbers. The set of 3 numbers is the security number that is necessary in order to process your request.
ENTER 3 Digit Security Code
BILLING ADDRESS:
BILLING ZIP CODE
I, AS THE CREDIT CARD HOLDER, VERIFY THAT I AM SUBMITTING THIS ONLINE-CONSULTATION REQUEST FOR A MEDICAL PRESCRIPTION AND I AUTHORIZE THE CHARGES STATED TO BE MADE TO MY CREDIT CARD (I understand that if I later dispute this charge as "unauthorized" I will be subject to criminal prosecution for credit card fraud). 
If credit card holder name is different than the person submitting consultation, you must verify that you have been given authorization to use this credit card:  I VERIFY THAT I HAVE BEEN GIVEN AUTHORIZATION BY CREDIT CARD HOLDER TO USE ABOVE CREDIT CARD.( I understand that if this charge is disputed by credit card holder as unauthorized, I will be subject to penalties of criminal prosecution for credit card fraud.)YES NO
AVAILABLE IN UNITED STATES ONLY 
Services not available in Arkansas, Illinois, or Florida 

You can choose either to receive a written prescription by mail which you can fill at your local United States pharmacy, or to have your prescription called into your local United States pharmacy, or have your prescription faxed to Murray Avenue Apothecary and receive the actual medication by mail.

Medical Wellness Center does not sell or dispense any medications and we are not affiliated with any pharmacies.  For pricing and price comparisons, you need to contact the pharmacy directly.
 
 

1. First check only ONE of the three choices below:
1. Receive Written prescription:
Receive written prescription for one year of refills  by mail in approximately 7 -15 days which you can fill at most any local United States pharmacy of your choice.
2. Prescription called into your local pharmacy:
Prescription for one year of  refills called into any major local United States pharmacy of your choice rather than receiving a prescription by mail. If approved, your prescription will be called into a pharmacy of your choice in 3-7 days. There is no extra charge for this service for refill prescriptions and your credit card will be billed the $75 consultation fee and regular S & P processing fee of $ 9.50. If you are requesting your prescription to be called into your pharmacy, please enter the complete phone# including area code, name and address of pharmacy where you choose to fill your prescription ( The prescription can only be called into your local U.S. pharmacy.  It can not be called in, faxed or filled at an internet pharmacy, foreign pharmacy, Canadian pharmacy or pharmacies such as Drugstore.com or an internet version of a local pharmacy such as CVS.com etc. ) 
3. Prescription faxed to Murray Avenue Apothecary 
Choose to have your prescription faxed to either Murray Avenue Apothecary and have the medication mailed directly to you.  ]
Murray Avenue Apothecary:  412-421-4996
Only if you are choosing to fill your prescription online and have  Murray Avenue Apothecary ship the medication to you check below:
Please check here authorizing Murray Avenue Apothecary to fill your prescription. Your prescription will be forwarded to Murray Avenue Apothecary. Your medication will be shipped directly to your shipping address that you provided to the pharmacy and you will be billed by Murray Avenue Apothecary for the medication . Please check directly with the pharmacy for pricing, this pharmacy offers discounts for medication not covered by insurance or if you do not have insurance.  Medical Wellness Center will only bill you for the online consultation fee($75.00 + 9.50 or 20 Express  S & P)
If you have any questions in regards to shipping status and tracking information you need to contact the pharmacy directly:    Murray Avenue Apothecary 412-421-4996. 
2. Next select whether you want BRAND NAME Avodart or Generic Avodart (dutasteride 0.5mg)  and quantity # 90 with 3 refills or # 30 with 11 refills: (Make sure you check FIRST with your chosen pharmacy the pricing of Brand Name Avodart vs generic dutasteride.  There is often a big price difference.  If you select brand and then later find out it is too expensive there is a $25 service fee to Medical Wellness Center to change to generic)
BRAND NAME Avodart # 90 with 3  refills 
BRAND NAME Avodart #30 with 11 refills
Generic Avodart -Dutasteride 0.5mg # 90 with 3  refills 
Generic Avodart -Dutasteride 0.5mg #30 with 11 refills 
3. Finally select whether you want regular service (7-15 days) or Express 24 hour service.
REGULAR SERVICE:  Consult reviewed within approximately 3-7 business days and your prescription is called into your local pharmacy or faxed to Murray Avenue Apothecary. If you selected to receive a written prescription, you will receive the written prescription by mail in approximately 7- 15 days which you can take to most any local United States pharmacy of your choice and fill.   Processing fee $9.50.
EXPRESS SERVICE: Consult reviewed and prescription called into most any local United States pharmacy of your choice or faxed to Murray Avenue Apothecary  within approximately 24 hours.  Express processing fee $20.
Please check here if you are  requesting our EXPRESS  24 hour review  and processing of your  medical evaluation.  If you checked yes and you are approved  you will be billed a $20 express processing fee. 
IF YOU ARE REQUESTING EXPRESS SERVICE CALLED INTO A PHARMACY MAKE SURE YOU ENTER THE NAME, ADDRESS AND PHONE NUMBER OF YOUR LOCAL UNITED STATES PHARMACY BELOW:
If you are requesting express service, please enter complete phone# including area code, name and address of pharmacy where you choose to fill your prescription.  If you are selecting Murray Avenue Apothecary just write in your choice, you do not need to include phone number.   The prescription can only be called into your local U.S. pharmacy.  It can not be called in, faxed or filled at an internet pharmacy, foreign pharmacy, Canadian pharmacy or pharmacies such as Drugstore.com or an internet version of a local pharmacy such as CVS.com etc. 
By submitting this consultation form, I certify:

I am a  male 18 years of age or older.
I have read and agree to Waiver of Liability.
I understand the side effects of this medication and adverse effect. 
I understand that Avodart is not to be taken by women or anyone under the age of 18.
I understand that crushed or broken capsules MUST not be handled by women who might be pregnant.
I am aware that I need to inform my doctor that I am taking  Avodart if I have a PSA blood test. Avodart decreases PSA levels by 50% and adjustments are necessary when testing for or monitoring PSA levels for Prostate cancer
I do not have any of the contraindications to therapy.
I do not have a current prescription for Avodart from another physician. If currently taking Propecia, I am aware that I must first discontinue Propecia therapy before initiating therapy with Avodart
I understand that I must NOT combine Avodart with Propecia or Proscar
I understand that my credit card will be billed $75.00 (plus S&P $9.50 or $20 for express service) for the medical  consultation if approved, if not approved there is no charge for the consultation. If approved I understand I receive a written prescription or the prescription is called into a pharmacy for Avodart  valid for one year - I am not purchasing medication  but rather the online consultation service.  I understand that by submitting this form it's an "electronic signature" of a binding agreement that I agree to pay the $75.00 consultation fee plus S & P  if approved and understand that there are no refunds for any circumstances even if  I later change my mind and decide not to fill the prescription for any reason or take the medication or I am advised not to take this medication by another physician.  I understand that whether I choose to fill the prescription or not or whether I change my mind and decide not to take the medication, there are absolutely NO refunds for the online consultation fee.  It is YOUR responsibility to make sure the pharmacy you list can provide you with the medication.  Also, if a pharmacy refuses to fill a valid  prescription issued by Medical Wellness Center due  to do failure to verify your billing/shipping/& or Credit card information that you provided to the pharmacy or failure of your payment authorization to them we do NOT refund the consultation fee. 

I have answered all the questions truthfully and I understand that by clicking submit I agree to all the terms and conditions including that my credit card will be charged the above stated amount for the consultation if approved.

Please CONFIRM your selection of BRAND NAME Avodart or Generic dutasteride 0.5mg
*****Check first with your pharmacy regarding pricing - we will NOT call a pharmacy to change to the generic if you later find out it is too expensive!  It is YOUR responsibility to check first with the pharmacy. There will be NO changes!

Brand Name Avodart only-make sure you check with your pharmacy first for price difference between the brand name and the generic dutasteride equivalent.  If you select brand name Avodart, we can not later change it to generic dutasteride 0.5mg. 
Generic Avodart =dutasteride 0.5mg 


Please CONFIRM YOUR SELECTION made above of receiving written prescription  or your prescription called into local U.S. pharmacy or receive your medication from Murray Avenue Apothecary :

Option 1 :  receive written prescription by mail in 7-15 days.
Option 2 : have prescription called into a local U.S. pharmacy. Please confirm pharmacy phone # below
Option 3 :Prescription faxed to Murray Avenue Apothecary
 

If you are choosing (option 2, 3 or 4) to have your prescription called into your local pharmacy or faxed to Murray Ave Apothecary, please confirm your selection of whether you want regular service or Express service.

REGULAR SERVICE: No extra charge 3 - 7 days :  Prescription called into your pharmacy or faxed to Murray Ave n 3-7 days- complementary.
EXPRESS SERVICE: $20 express processing fee - your prescription will be called into your local pharmacy or faxed to Murray Ave in approximately 24 hours or less.


Click SUBMIT button for Physician Consultation for Avodart REFILLS
You may submit Consultation Form over the Internet (secure server) by clicking the SUBMIT button. 

For any questions
email at wellnessmd@medicalwellnesscenter.com
Email to contact Medicall Wellness Center: Hair-loss treatment for MenTo contact Medical Wellness Center - Hair-loss treatment for Men with any questions, please Email us.
PHONE  NUMBER: 
(US ONLY)		 617-367-8887
Medical Wellness Center
Boston, MA