Prevident Doctor Consultation Form

PREVIDENT Medical Consultation Form

Prevident Prescription Flouride Treatment online

Please fill in all fields and respond to all questions honestly and completely so that a physician can review your consultation and prescribe PREVIDENT if approved - you will receive a written Prevident prescription with 6 refills or your prescription can be called into most local United States pharmacy of your choice. If the consulting physician determines that Prevident is not appropriate for you, there is NO charge for this consultation. Available in the United States Only.
This Service is NOT Available in ILLINOIS, ARKANSAS OR FLORIDA 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 risks and side effects associated with PREVIDENT. Please be sure to read PREVIDENT CONTRAINDICATIONS, WARNINGS & SIDE-EFFECTS and confirm that you do NOT have any contraindications, understand the warnings and agree to the Waiver of Liability before filling out this consultation. Failure to answer truthfully and completely could result in serious consequences!
Click here to read all the above stated contraindications and conditions before filling out the medical consultation form: I have read the previous Prevident 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: SEX: FemaleMale Date of Birth(MM/DD/YY): Current Age: Height (inches): Weight:

Please list all current Medical Conditions:

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 including vitamins.
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 been diagnosed by your dental professional to have a high susceptibility to dental decay , cavities or tooth enamel loss YES

Do you have a predisposition to dental decay and cavities or have a history of cavities and enamel loss? YES NO

Do you have professional dental cleanings by your dental professional on a regular annual or biannual basis?YES NO

Are you currently Pregnant or attempting to become pregnant? YES NO

Are you currently Breast-feeding? YES NO

Are you allergic or hypersensitive to Sodium Fluoride? YES NO

Are you currently suffering from kidney disease? YES NO

Are you currently on a Physician-Prescribed Low-salt/Salt-Free Diet? YES NO

Have you ever had a kidney transplant?YES NO

Do you active stomach ulcers? YES NO

Are you currently being treated for cancer?YES NO
If yes, please explain:

Are you currently undergoing Head and Neck radiation for cancer? YES NO

Have you had a physical exam in the last two years?YES NO
	Do you smoke?YES NO
Have you been diagnosed with HIV disease? YES NO

CURRENT MEDICAL CONDITIONS & PAST MEDICAL HISTORY
Do you have or have you ever had any of the following conditions?
Kidney Disease	Renal failure	Kidney dialysis
Liver disease	HIV Positive	Osteoporosis
Xerostomia (dry mouth)	Periodontal Disease	Tooth Loss
Organ Transplant	Kidney Transplant	BoneMarrow Transplant
Compromised ImmuneSystem	Seizures	Anxiety
Coronary Artery Disease	Heart Attack	Heart disease
High Blood Pressure	Stroke	Diabetes
Thyroid disease	Depression	Endocrine Disorders

Are you currently taking steroids? YES NO

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:
Do any of your immediate family members have any of the following medical problems?
Diabetes	Liver Disease	Stroke
Osteoporosis	Periodontal Diseases	Tooth Loss/Dentures
High blood pressure	Heart disease	Arteriosclerosis
Kidney Disease	Gallbladder disease	Cancer
Are there any other diseases than run in your family?

**Dental History**
Have you been diagnosed with a predisposition to dental cavities and tooth enamel loss by your dental professionalYes No
Do you suffer from Xerostomia or dry mouth which increases susceptibility to cavities?Yes No
Have you undergone head and neck radiation in the past which increases susceptibility to dental caries?Yes No
At what age did you first experience susceptibility to cavities and enamel loss?
Please describe the condition of your teeth, cavities, decay and enamel loss:
Please describe all past treatments for dental cavities and enamel loss
Have you ever used Prevident 5000 Plus or Prevident gel in the past?YES NO If Yes, please describe your response to Prevident and whether you experienced any side effects:

Prevident® (1.1% Sodium Fluoride) comes in several formulations. We prescribe both Prevident® Gel(this is not a dentrifice and has no cleansing ability and must be used in conjunction with your regular toothpaste) and the Prevident® 5000 Plus cream toothpaste. Both Prevident Gel and Prevident 5000 Plus must NEVER be swallowed. Also when using either the Prevident gel or Prevident 5000 Plus toothpaste you must NOT rinse after applying - only SPIT out excess. Please check below whether you want a Differin® Gel or Differin® Cream. If you do not indicate a preference, our physicians will make the determination based on your history.

Prevident® 5000 Plus toothpaste Prevident® Gel

**PERSONAL and PAYMENT INFORMATION**
**Available in the United States Only**
***THIS SERVICE IS NOT AVAILABLE TO ILLINOIS AND ARKANSAS OR FLORIDA***
FULL NAME:
ADDRESS:
CITY:
STATE:	ZIP CODE
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 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.
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.

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. 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. 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. 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 Amazon.com or an internet version of a local pharmacy such as CVS.com etc.
Name, Phone # Address of EXPRESS Pharmacy.

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: -

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:
Name, Phone # Address of EXPRESS Pharmacy


Click SUBMIT button for Physician Consultation for PREVIDENT
You may submit Consultation Form over the Internet (secure server) by clicking the SUBMIT button. For any questions & fastest reply contact us by email at wellnessmd@medicalwellnesscenter.com

To contact Medical Wellness Center -with any questions, please Email us.

PHONE NUMBER: (US ONLY)	617-367-8887
Medical Wellness Center Boston, MA