Prevident REFILL Form

Fields marked with an * are required

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Welcome back. After you initial Prevident consultation, depending on your response to therapy, you can receive a prescription for 12 Prevident refills valid in most local, United States pharmacies. If approved, the refill consultation is only $75.00 plus processing. 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.

Be sure to read PREVIDENT CONTRAINDICATIONS, WARNINGS & SIDE-EFFECTS. Then, 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: *

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Available in the United States Only.
Not Available in Arkansas, Florida or Illinois

The medical information you supply is subject to ALL patient/doctor privilege laws.

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MEDICAL HISTORY

First and Last Name: *

Medical Wellness Center Membership Number:

Please indicate your peference below for Prevident Gel or Prevident 5000 Plus Cream: *

Prevident® 5000 Plus toothpaste
Prevident® Gel

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.

Date of Birth (MM/DD/YY) *

Age

Sex

Male
Female

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Please describe the effect Prevident® Gel or 5000 Plus Cream had for you:

Did you experience any side effects:

If yes, have these symptoms resolved?

If you experienced side effects, 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

Please list all current medical conditions:

Do you take any prescription medication?

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.

For example: aspirin -for migraines, Unisom -difficulty sleeping etc.

Do you have any known allergies to Medicines?

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

Do you have a predisposition to dental decay and cavities or have a history of cavities and enamel loss?

Do you have professional dental cleanings by your dental professional on a regular annual or biannual basis?

Are you currently Pregnant or attempting to become pregnant?

Are you currently Breast-feeding?

Are you allergic or hypersensitive to Sodium Fluoride?

Are you currently suffering from kidney disease?

Are you currently on a Physician-Prescribed Low-salt/Salt-Free Diet?

Have you ever had a kidney transplant?

Do you active stomach ulcers?

Are you currently being treated for cancer?

If yes, please explain:

Are you currently undergoing Head and Neck radiation for cancer?

Have you had a physical exam in the last two years?

Do you smoke?

Have you been diagnosed with HIV disease?

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CURRENT MEDICAL CONDITIONS & PAST MEDICAL HISTORY

Do you have or have you ever had any of the following conditions?

Kidney Disease
Liver disease
Xerostomia (dry mouth)
Organ Transplant
Compromised ImmuneSystem
Coronary Artery Disease
High Blood Pressure
Thyroid disease
Renal failure
HIV Positive
Periodontal Disease
Kidney Transplant
Seizures
Heart Attack
Stroke
Depression
Kidney dialysis
Osteoporosis
Tooth Loss
BoneMarrow Transplant
Anxiety
Diabetes
Heart disease
Endocrine Disorders
None of the Above

Are you currently taking steroids?

Have you had surgery in the last 3 months?

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

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FAMILY HISTORY

Do any of your immediate family members have any of the following medical problems?

Diabetes
Osteoporosis
High blood pressure
Kidney Disease
Liver Disease
Periodontal Diseases
Heart disease
Gallbladder disease
Stroke
Tooth Loss/Dentures
Arteriosclerosis
Cancer
None of the Above

Are there any other diseases than run in your family?

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Dental History

Have you been diagnosed with a predisposition to dental cavities and tooth enamel loss by your dental professional

Do you suffer from Xerostomia or dry mouth which increases susceptibility to cavities?

Have you undergone head and neck radiation in the past which increases susceptibility to dental caries?

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

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PERSONAL AND PAYMENT INFORMATION

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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 *

Email *

Name of Credit Card Holder

Credit Card Type

Discover
Mastercard
Visa

Credit Card Number *

Expiration Date (MM/YY) *

3 Digit Security Code *

BILLING ADDRESS:

Billing Zip Code

Credit Card Verification: *

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.)

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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) (Not available in CA, NY, MA, VT, RI, CT and IN)
2. Have your prescription called/Eprescribed into your local U.S. pharmacy 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 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.

Select Prescription Method: *

1. RECEIVE WRITTEN PRESCRIPTION: (Not available in CA, NY, MA, VT, RI, CT and IN)
ARMACY:

1. First, check only ONE of the two 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. (Not available in CA, NY, MA, VT, RI, CT and IN)

2. PRESCRIPTION CALLED/ePRESCRIBED INTO LOCAL PHARMACY: Prescription for one year of refills called/Eprescribed into most 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). Your credit card will be billed the $75 consultation fee and regular processing fee of $ 9.50. If you are requesting your prescription to be called into your pharmacy, you will need to 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 cannot 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 or Costco.com etc.)

If you selected Option 2, prescription called into local pharmacy, enter pharmacy information:

Select Regular or Express Service: *

REGULAR SERVICE: No extra charge, regular processing fee of $9.50: Prescription called/Epresribed into your pharmacy 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 in approximately 24 hours.

2. Next, choose whether you want Regular or Express Service:
If you are choosing to have your prescription called into your local pharmacy, please elect whether you want Regular service or Express service.

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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 $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.

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Confirm Selection: *

Option 1: Receive written prescription by mail in 7-15 days. (Not available in CA, NY, MA, VT, RI, CT and IN)
Option 2: Have prescription called/ePrescribed into a local U.S. pharmacy. Please confirm pharmacy phone # below

Please CONFIRM YOUR SELECTION made above of receiving written prescription or your prescription called into local United States pharmacy:

If you selected Option 2, prescription called/ePRESCRIBED into local pharmacy, confirm pharmacy information:

Confirm Regular or Express Service:

REGULAR SERVICE
EXPRESS SERVICE

If you are choosing (option 2 or 3) to have your prescription called/ePRESCRIBED into your local pharmacy, please confirm your selection of whether you want regular service or Express service.

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Click SUBMIT button (secure server) to order Prevident Refill Consultation

For any questions and fastest reply contact us by

email at wellnessmd@medicalwellnesscenter.com

Phone (United States Only): 617-367-8887

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