PREVIDENT REFILL Consultation Form
Prevident Prescription Flouride Treatment onlineWelcome back.  After you initial consultation and  Prevident prescription depending on your response to  therapy, you can receive a  written prescription for 12 Prevident refills valid in most local U.S. pharmacies.    If approved, the refill  consultation is only $75.00 plus $9.50 handling and processing fee. Your Medical Wellness Center membership number assigned upon approval into the program is required.  If you do not have this available, you can Email us for your membership number.  Please fill in all fields and respond to all questions honestly and completely so that a physician can review your refill consultation and prescribe Prevident if approved. If the consulting physician determines that Prevident is no longer appropriate for you, there is NO charge for this consultation. 
Available in the United States Only.
Not Available in Arkansas, Florida or Illinois
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: 
Medical Wellness Center Membership Number:
SEX: FemaleMale 
Date of Birth(MM/DD/YY):          Current Age: 
Height (inches):                   Weight: 
Please describe the effect Prevident® Gel or 5000 Plus Cream had for you:

Please indicate your preference below for either Prevident 5000 Plus toothpaste refills or Prevident Gel refills 
Prevident® 5000 Plus toothpaste Prevident® Gel
 
Did you experience any side effects: YES NO
If yes, have these symptoms resolved?YES NO
If yes, please describe symptoms:
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)
CLICK HEREYou can choose to have your 12 Prevident®  prescription refills called into the pharmacy rather than receiving a prescription by mail at no extra charge. If approved, your prescription will be called into most any major local U.S. pharmacy of your choice. There is no extra charge for this service for refill prescriptions, and your credit card will be billed the $75.00 consultation fee and regular S & H processing fee of $ 7.00. 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
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? YESNO
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
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
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:
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 
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.

For refill prescriptions you have the option of:

1.  Receiving a WRITTEN prescription by mail which you can fill at most any local United States pharmacy of your choice (approximately 7- 15 days)

2.  Have your prescription called into your local U.S. pharmacy or faxed to Murray Avenue Apothecary or RXUSA Pharmacy (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) at NO EXTRA charge in 3 - 7 days, COMPLEMENTARY call in service.

If you select option # 2, you can also select EXPRESS 24 hour processing where your prescription will be called into your local pharmacy or faxed to Murray Avenue Apothecary or RXUSA in approximately 24 hours.  If you select EXPRESS 24 hour processing you will be charged a $20 express processing service fee rather than the regular processing fee of $9.50. 
Please check here if your are selecting EXPRESS 24 hours service - $20 express processing fee


Check only ONE of the three choices below:

1. Receive Written prescription:
Receive written prescription 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 written prescription by mail. If approved, your prescription will be called into a pharmacy of your choice. There is no extra charge for this service for refill prescriptions  (unless you are choosing the Express Refill call in service) and your credit card will be billed the $75 consultation fee and regular S & H 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 or RXUSA:
Choose to have your prescription faxed to either Murray Avenue Apothecary or RXUSA pharmacy and have the medication mailed directly to you.   If you select this choice you then must select below whether you want Murray Ave Apothecary or RXUSA. (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)

Only if you selected to have your prescription faxed to and filled by Murray Avenue Apothecary or RXUSA pharmacy please select your choice below: (It is imperative that you check first with the pharmacies on pricing of the medication. Medical Wellness Center only bills you for the consultation fee and the pharmacy you select will bill you directly for the medication itself. 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.)

Murray Avenue Apothecary:    412-421-4996
Please check here authorizing Murray Avenue Apothecary to fill your prescription, and 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. Medical Wellness Center will only bill you for the online consultation fee ($75.00 + 9.50 S & H or $20 if selecting express service)
 

RXUSA PHARMACY:   1 800-764-3648 or 1 800-798-7248 or  516-467-2500
(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)
Please check here authorizing RXUSA Pharmacy 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 ($75.00 + 9.50 S & H or $20 if selecting express service), you will be billed separately by RXUSA pharmacy for the medication. You need to call the pharmacy directly for pricing

 
If you are choosing to have your prescription called into your local pharmacy or faxed to Murray Ave Apothecary or RXUSA, please select whether you want Regular service or Express service.
REGULAR SERVICE:  No extra charge, regular processing fee of $9.50:  Prescription called into your pharmacy or faxed to Murray Ave or RXUSA in 3-7 days.
EXPRESS SERVICE:  $20 express processing fee  instead of the $9.50 regular processing fee- your prescription will be called into your local pharmacy or faxed to Murray Ave or RXUSA in approximately 24 hours.
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 $75.00 and $9.50 or $20 S & H  for the refill medical consultation if approved (no refunds for this consultation service), if not approved there is no charge.  I understand that by submitting this form I agree to pay the $75.00 consultation  if approved and understand that there are no refunds for any circumstances even if  I later change my mind and decide not to take  the medication for any reason.  I understand that once I submit my consultation for review there are absolutely NO cancellations. 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 or foreign or Canadian pharmacies.
I certify that I  have answered all the questions truthfully.

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

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
Option 4 : Prescription faxed to RXUSA pharmacy
(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)
If you are choosing (option 2, 3 or 4) to have your prescription called into your local pharmacy or faxed to Murray Ave Apothecary or RXUSA, 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 or RXUSA in 3-7 days- complementary.
Express Service:  $20 express processing fee - your prescription will be called into your local pharmacy or faxed to Murray Ave or RXUSA in approximately 24 hours or less.


Click SUBMIT button for Physician Refill 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
Email to contact Medical Wellness CenterTo contact Medical Wellness Center -with any questions, please Email us.

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