PERIOSTAT Medical Consultation Form
Periostat prescription onlinePlease fill in all fields and respond to all questions honestly and completely so that a physician can review your consultation and prescribe PERIOSTAT if approved. If the consulting physician determines that Periostat is not appropriate for you, there is NO charge for this consultation.
Available in the United States Only.
Not available in Illinois and Arkansas and 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 PERIOSTAT.   Please be sure to read Periostat 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 conditions before filling out the medical consultation form: I have read the previous Periostat 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 Periodontal disease -periodontitis 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 Tetracycline antibiotics? YES NO
Are you allergic or hypersensitive to any antibiotics? YES NO
Are you currently on anticoagulant blood-thinning medications? YES NO
Are you taking Coumadin, Warfarin or Heparin? YES NO
Do you have a predisposition to oral candidiasis or do you have a history of frequent oral candidiasis or thrush? YES NO
Do you have LIVER DISEASE, RENAL or KIDNEY disease or are you on Dialysis? YES NO
Have you ever had a  kidney or liver transplant?YES NO 
Do you have diabetes? YES NO
Do you have osteoporosis? YES NO
Are you currently taking Dilantin or Phenytoin or Anti-Seizure Medication? YES NO
Are you currently taking Warfarin or Coumarin-type anticoagulants? YES NO
Are you currently being treated for cancer?YES NO 
If yes, please explain: 
Have you had a physical exam in the last two years?YES  NO 
Do you smoke?YES NO 
Do you consume more than 2 servings of alcohol per day?
  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 Osteoporopsis
Leukemia Sickle Cell Anemia History oral Candidiasis
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? 
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
At what age were you first experience periodontal disease?
Please describe your periodontal disease: Age of onset, severity, gum condition, gum bleeding, receding gums, tooth loss etc.
Please read descriptions below and check which best describes the severity of your Periodontal disease?
Gingivitis Mild Periodontitis Moderate Periodontitis Severe Periodontitis 
GINGIVITIS
Gingivitis early reversible periodontal diseaseGingivitis 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
early periodontitis  - Periostat prescriptionnIf 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
Periostat prescription:  periodontitis moderateIf 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
Periostat prescription:  severe periodontitisIf 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.
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 
 

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
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
 


 



Click SUBMIT button for Physician Consultation for PERIOSTAT
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