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Are you currently undergoing
Head and Neck radiation for cancer? YES NO |
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Do you consider anything in your medical history to be relevant,
please give details.
If unsure, please ask your regular doctor
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AVAILABLE IN UNITED
STATES ONLY
Services not available
in Arkansas, Illinois, or Florida
You can choose to fill your prescription
and your local United States pharmacy.
In addition you can choose either
Regular or 24 hour Express Service:
You can choose to receive a written
prescription and fill your prescription at most any local United
States pharmacy of your choice or EXPRESS service and have your prescription
called into the local United States pharmacy of your choice.
Our prescriptions can only be
filled at a local United States pharmacy of your choice, they can not be
filled at internet or foreign or Canadian or internet versions of pharmacies.
If you would prefer to receive your medication by mail you can choose to
have your prescription faxed to one of two approved local United States
pharmacies that will mail your medication directly to you. The pharmacy
will contact you and fill the prescription and mail the medication directly
to you. (Medical Wellness Center has no
financial ties to either of these pharmacies. They were chosen for
their outstanding customer service, excellent compounding expertise, and
reliability. They only dispense 100% FDA approved manufactured medications.)
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 choose whether
you want to fill you prescription at your local U.S. pharmacy or at Murray
Avenue Apothecary or RXUSA pharmacy. Choose only
ONE of these three choices.
Prescription
filled at your local United States pharmacy:
Choose
to fill prescription at your local pharmacy: Please
check here if you are choosing to fill your prescription at your local
United States pharmacy. If you want to purchase your prescription
from your local pharmacy, you then can select whether you want Regular
service and wait 7-15 days to receive your written prescription by mail
or whether you want Express service and your prescription is called into
your local pharmacy in approximately 24 hours.
Murray Avenue Apothecary:
412-421-4996
Murray Avenue Apothecary is a specialized
compounding pharmacy. This pharmacy has excellent pricing, especially for
medications that are not covered by insurance or for those who do not have
insurance. Please check FIRST with the pharmacy in regards to pricing
of the medication. Only if you are choosing to fill your prescription
online and have Murray Avenue Apothecary ship the medication to you
check below:
Authorized
Murray Avenue Apothecary to fill prescription : Please
check here authorizing Murray Avenue Apothecary to fill your prescription.
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 . Medical Wellness Center will only bill you for the
online consultation fee.
RXUSA PHARMACY:
800-764-3648 or 800-798-7248 or 516-467-2500
Fill your prescription with RXUSA
directly Please check FIRST directly with the pharmacy in regards
to pricing of the medication. (RXUSA
pharmacy can only ship to CT, DE, HI, IN, KS, ME, MO, NJ, NM, NV, NY, OH,
OK, RI, SC, UT, VT, WA, WI and WY)
Authorized
RXUSA PHARMACY to fill prescription for choice indicated: Please
check here authorizing RXUSA Pharmacy to fill your prescription. Your prescription
will be forwarded to RXUSA and your medication will be shipped directly
to your shipping address that you provided to the pharmacy and you will
be billed by RXUSA for the medication. Medical Wellness Center will only
bill you for the online consultation fee:
If you have any questions
in regards to shipping status and tracking information you need to contact
the pharmacy directly: RXUSA Pharmacy 516-467-2500 or
Murray Avenue Apothecary 412-421-4996.
2. Next after making
this selection then choose 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 will receive a 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 or have your prescription faxed to Murray Ave Apothecary
or RXUSA in 3-7 days. Processing fee $10.35
EXPRESS
SERVICE: Consult
reviewed and prescription within approximately 24 hours called into most
any local United States pharmacy of your choice or faxed to Murray Avenue
Apothecary or RXUSA pharmacy. Express
processing fee $20.
Please
check here if you are requesting our EXPRESS review and
processing of your medical evaluation. If approved your
prescription will be called into your LOCAL United States pharmacy
of your choice within 24 hours. 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 or RXUSA pharmacy 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.
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By submitting this consultation form, I certify: |
I am am an adult
18 years of age or older.
I
understand that Prevident is not to be taken by anyone under the age of
18 without the DIRECT supervision specifically by the prescribing physician
who is examining and closely monitoring the administration.
I understand that the use of Prevident by children can result in serious
consequences and fluorosis.
I have read and
agree to Waiver of Liability.
I
understand the side effects of this medication from accidentally swallowing
can result in nausea, Stomach upset, vomiting, weakness, seizures to loss
of consciousness.
I
understand that a rare side effect of Prevident is a change in color or
appearance of the teeth. Also Prevident may cause irritation and
it may be necessary to discontinue use if gum irritation occurs.
I
understand that Prevident is not to be taken by anyone with Kidney disease.
I
understand that Prevident is NOT to be taken by anyone who is pregnant
or attempting to become pregnant because Prevident may cause harm to the
fetus.
I
understand that taking Prevident should not be used by anyone who is on
a physician-prescribed low-salt/Salt-free diet
I
am aware that in order to be eligible to receive a Rx, I must have been
positively diagnosed with increased susceptibility to dental cavities
and enamel loss, I must be continuing with routine professional cleanings
and I need to inform my doctor that I am taking Prevident.
I do
not have any of the contraindications to therapy and I have read and understand
the contraindications and possible side effects
I
am not allergic or hypersensitive to sodium fluoride or any of the inactive
ingredients of Prevident 5000 Plus or Prevident Gel..
I
do not have a CURRENT prescription for Prevident from another physician,
as Medical Wellness Center does NOT fill prescriptions, we only issue written
prescription valid in most major U.S. local pharmacies.
I
understand that my credit card will be billed $49.95 and $10.35 S &
H for the medical consultation if approved (no refunds for this consultation
service under any circumstances), if not approved there is NO charge.
I understand that by submitting this form I agree to pay the $49.95 consultation
and S& H fees 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 I receive or decide not to take
the medication for any reason. I understand that I am not purchasing medication
and can choose most major local United States pharmacy to fill the prescription.
Prescriptions not honored by other internet services or internet pharmacies.
Please check here
if you are requesting our EXPRESS (available in United States
only) review and processing of your medical evaluation.
If approved your prescription will be called into a pharmacy of your
choice within approximately 24 hours. If you checked yes and you
are approved you will be billed a $20 express S & H processing
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 made above of
receiving written Rx, Express Service called into local U.S. pharmacy:
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Option
1 : Regular Service - receive written prescription by mail in 7-15 days
Option
2 : EXPRESS Service - have prescription called into a local U.S. pharmacy
within approximately 24 hours
If
you selected Express service, confirm the name and phone number of your
Local United States Pharmacy below:
Option
3: Murray Avenue Apothecary ships you the medication to your home - Regular
Service: consult reviewed and faxed to Murray Avenue Apothecary in 3 -
7 days
Option
4: Murray Avenue Apothecary ships you the medication to your home - Express
Service: consult reviewed and faxed to Murray Avenue Apothecary in approximately
24 hours
Option
5: RXUSA Pharmacy ships you the medication to your home - Regular Service:
consult reviewed and faxed to RXUSA in 3 - 7 days
Option
6: RXUSA Pharmacy ships you the medication to your home - Express Service:
consult reviewed and faxed to RXUSA in approximately 24 hours
(RXUSA
pharmacy can only ship to CT, DE, HI, IN, KS, ME, MO, NJ, NM, NV, NY, OH,
OK, RI, SC, UT, VT, WA, WI and WY)
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To
contact Medical Wellness Center -with any questions, please Email us. |
PHONE NUMBER:
(US ONLY) |
617-367-8887 |
Medical Wellness Center
Boston, MA
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