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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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Periodontal Disease History
Have you been diagnosed
with periodontal disease by your dental professional
Yes
No |
Have you been treated
for or are you currently being treated for periodontal disease?Yes No |
Please list types of treatment for periodontal
disease you've received or are receiving |
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Please describe your periodontal disease:
Age of onset, severity, gum condition, gum bleeding, receding gums, tooth
loss etc.
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Please read descriptions below and check
which best describes the severity of your Periodontal disease?
Gingivitis Mild
Periodontitis Moderate
Periodontitis Severe
Periodontitis |
GINGIVITIS
Gingivitis
is an inflammation of gums and the earliest stages of periodontal disease.
Daily a clear sticky film called plaque made up of bacteria builds up on
the surface of the teeth. Plaque is easily removed by brushing &
flossing. If plaque is allowed to build up it comes in contact with
the gum tissue and the gums become red and inflamed and may bleed when
you brush your teeth. Gingivitis is reversible through professional
cleaning by your dental professional and daily dental hygiene. If
left untreated it can progress to periodontitis and tooth loss. |
EARLY PERIODONTITIS
If
the plaque is not removed, it hardens into deposits called tartar which
cannot be removed by just brushing and flossing but needs to be mechanically
removed by your dental profession in a procedure called scaling and root
planing during routine dental cleanings. These hard tartar
deposits and their associated bacteria cause a severe inflammation and
the body responds trying to fight the infection by produced tissue-destroying
enzymes, collagenases. These enzymes made by your own body end up attacking
your body's own tissue destroying gums, ligaments and bones that support
your teeth and eventually result in tooth loss. |
MODERATE PERIODONTITIS
If
left untreated periodontitis progresses due to the chronic, long-term nature
of the bacterial infection and the tissue-destroying enzyme body response.
These enzymes start to eat at the ligaments and bones that support the
teeth. First, a small "pocket" forms between the tooth and the gums
where food can lodge and bacteria live and this process progresses down
the tooth surface which results in the pockets getting deeper and deeper.
Your dentist using a probe and with X-rays determines how deep the
tooth pockets are and how advanced the disease is. |
SEVERE PERIODONTITIS
If
left untreated, periodontal disease progresses to the point where
bone loss is so severe that the tooth becomes loose and eventually lost.
However, even severe periodontitis can respond to aggressive treatment:
combination of professional dental cleaning with scaling and root planing
(SRP) which mechanically removes bacteria combined with PERIOSTAT which
inhibits the your body's response of producing tissue-destroying enzymes
that ultimately results in tissue destruction and tooth loss. Periostat
plus professional dental cleanings & SRP is more effective in treating
and halting the progression of periodontitis than just cleanings alone. |
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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 hr Express Service:
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. Choose only ONE of these two choices.
Prescription
filled at your local United States 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 to wait
7-15 days to receive your written prescription or whether you want Express
service and your prescription is called into your local pharmacy in approximately
24 hours.
Murray Avenue Apothecary:
1-412-421-4996
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. 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.
You must contact Murray Avenue Apothecary directly by phone ( 412-421-4996)
for actual pricing of the medication, and to provide your payment and shipping
information to the pharmacy. 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:
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 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 your prescription is faxed to
Murray Ave Apothecary in 3 -7 days. Processing fee $10.35
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 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, 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.
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
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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 Periostat is not to be taken by anyone under the age of
18
I have read and
agree to Waiver of Liability.
I understand
the side effects of this medication are similar to placebo and may
be mild nausea and stomach upset
I
understand that Periostat is not to be taken by anyone with LIVER disease
or anyone who has compromised renal function or kidney disease.
I
understand that Periostat is NOT to be taken by anyone who is pregnant
or attempting to become pregnant because Periostat may cause harm to the
fetus.
I
understand that taking Periostat may make oral contraceptives less effective.
Therefore if I am using birth control pills and taking Periostat I MUST
use an additional form of birth control while on Periostat to prevent pregnancy.
I am aware that Periostat is a known medication to cross the placenta and
causes harm to the developing fetus.
I
am aware that in order to be eligible to receive a Rx, I must have been
positively diagnosed with Periodontal disease, I must be continuing
with routine professional cleanings and I need to inform my doctor that
I am taking Periostat.
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 taking blood thinning medication, anticoagulants, such as Coumadin.
I
am not allergic or hypersensitive to Tetracycline or other antibiotics.
I do not have
a current prescription for Periostat from another physician.
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 any United States pharmacy to fill the prescription.
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. If you are requesting express service, please enter phone#,
name and address of pharmacy where you choose to fill your prescription.
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 United States
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
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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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