Avodart Dutasteride INITIAL Consult FORM
Fields marked with an * are required

Please fill in all fields and respond to all questions honestly and completely so that a physician can review your consultation and prescribe Avodart if approved.   If approved, you are issued a prescription good for six months of refills.  We do NOT sell or ship medication.

Do NOT combine Avodart (dutasteride) and Propecia (finasteride).  If you are currently taking Propecia (finasteride), discontinue finasteride before beginning therapy with dutasteride.  If the consulting physician determines that Avodart is not appropriate for you, there is NO charge for this consultation.

NOT  AVAILABLE IN ILLINOIS AND ARKANSAS AND FLORIDA
I have read the previous Avodart 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:
Click here to read the stated conditions before filling out the medical consultation form:

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

MEDICAL HISTORY
SEX
Do you take any prescription medication?
Do you currently use topical Minoxidil?
Do you have any known allergies to Medicines?
Have you had a physical exam in the last two years?
Do you presently have liver disease, liver function abnormalities, hepatitis or any medical disorder of liver function including but not limited to cirrhosis of the liver, liver cancer, jaundice etc
Are allergic to Avodart, dutasteride, finasteride , Propecia or any of the ingredients in Avodart?
Are you currently taking ORAL Nizoral (ketoconazole) or Sporanox (itraconazole)?
Are you currently taking PROPECIA or PROSCAR (finasteride)?
Do you have AIDS or a positive HIV test or have you recently been exposed to AIDS?
Are you currently taking Protease Inhibitors: Agenerase (amprenavir), Crixivan (indinavir), Viracept (nelfinavir), Norvir (ritonavir) or Invirase or Fortovase (saquinavir)?
Have you been diagnosed with prostate cancer?
Do you have BPH - benign prostatic hypertrophy ?
Are you currently being treated for cancer?
Do you smoke?
How much alcoholic beverages do you drink?

CURRENT MEDICAL CONDITIONS & PAST MEDICAL HISTORY
Do you have or have you ever had any of the following conditions?
Are you currently taking steroids?
Have you had surgery in the last 3 months?

FAMILY HISTORY
Does Male Pattern Hair Loss run in your family?
Do any of your immediate family members have any of the following medical problems?

HAIR LOSS HISTORY
Do you suffer from Male Pattern Baldness?
Have you been treated before for hair loss?
Check each treatment that you have undergone:
Was your hair loss

From the illustration below, choose which Norwood Classification of Hair Loss best describes your present condition:
Please select your current Norwood Classification:

PERSONAL AND PAYMENT INFORMATION
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
Credit Card Type
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.)

AVAILABLE IN UNITED STATES ONLY 
Services not available in Arkansas, Illinois, or Florida 


 You can choose one of the following choices: 

  1. Receive a written prescription by mail which you can fill at your local United States pharmacy. The prescription can not be filled or transferred to an internet or .COM pharmacy such as Costco.com or Amazon.com or at a foreign or Canadian pharmacy   (Not available  in CA, NY, MA, VT, RI, CT, or IN.  These states require the prescription to be electronically prescribed directly to your pharmacy)
  2. Have your prescription forwarded directly to Trinova Health Specialty Pharmacy and receive the actual medication itself by mail. (For medication pricing, you would need to contact Trinova Health directly at 813-551-1165 or contact@trinovahealth.com). The prescription is sent to Trinova Health, and the pharmacy will contact by phone or email to arrange for purchasing medication and shipping.
  3. EXPRESS 24 hours service:  Have your prescription called or electronically prescribed directly to your local pharmacy or Trinova Health Pharmacy

REGULAR SERVICE:  $10.35 Processing fee

EXPRESS SERVICE:  $20 Processing fee
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.
Select One of the Following Five Choices: *

Choose whether you want Regular Service (receive written prescription in 7-15 days, NOT available  in the states of CA, NY, MA, VT, RI, CT, NH OR IN, the prescription is sent directly to your local pharmacy), Medication sent directly from Trinova Health Pharmacy  or Express 24 hour Service.

The prescription can only be called into your local U.S. pharmacy or Trinova Health 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 RECEIVE WRITTEN Prescription to fill at your local California, New York, Massachusetts, Vermont, Rhode Island, New Hampshire, Connecticut, or Indiana pharmacy, the prescription has to be ePrescribed.  These states, CA, NY, MA, VT, RI, NH, CT, and IN,  will not accept written prescriptions.  Please enter the NAME, ADDRESS and Phone number of your local California, New York, Massachusetts, Vermont, Rhode Island, New Hampshire, Connecticut, or Indiana pharmacy.
REGULAR Service your consult will be processed in 3-7 business days.  EXPRESS Service in approximately 24 hours.
Next select whether you want BRAND name Avodart or Generic Avodart (dutasteride 0.5mg) and quantity # 90 with 1 refill or # 30 with 6 refills: *

Make sure you check FIRST with your chosen pharmacy for the pricing of Brand name Avodart vs generic Dutasteride.  There is a big price difference between brand and generic. BRAND name Avodart is as high as $2500 at the pharmacy.  If you select Brand and when find out the exorbitant price and want to change to generic, there is a $25 service fee to change. 

BY SUBMITTING THIS CONSULTATION FORM, I CERTIFY:
  • I am a male 18 years of age or older.
  • I have read and agree to Waiver of Liability.
  • I understand the side effects of this medication and adverse effect.
  • I understand that Avodart is not to be taken by women or anyone under the age of 18.
  • I understand that crushed or broken capsules MUST not be handled by women who might be pregnant.
  • I am aware that I need to inform my doctor that I am taking Avodart if I have a PSA blood test. Avodart decreases PSA levels by 50% and adjustments are necessary when testing for or monitoring PSA levels for Prostate cancer
  • I do not have any of the contraindications to therapy.
  • I do not have a current prescription for Avodart from another physician. If currently taking Propecia, I am aware that I must first discontinue Propecia therapy before initiating therapy with Avodart
  • I understand that I must NOT combine Avodart with Propecia or Proscar
  • I understand that my credit card will be billed $49.95 (plus either $10.30 Regular Processing or $20 Express Processing) for the medical consultation if approved. If not approved there is no charge for the consultation. If approved I understand I receive a written prescription or the prescription is called into a pharmacy for Avodart for six months of refills.  I understand that I am not purchasing medication but rather the online consultation service. I understand that by submitting this form it's an "electronic signature" of a binding agreement that I agree to pay the $49.95 consultation fee plus S & P 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 for any reason or take the medication or I am advised not to take this medication by another physician. I understand that whether I choose to fill the prescription or not or whether I change my mind and decide not to take the medication, there are absolutely NO refunds for the online consultation fee. It is YOUR responsibility to make sure the pharmacy you list can provide you with the medication. Also, if a pharmacy refuses to fill a valid prescription issued by Medical Wellness Center due to do failure to verify your billing/shipping/& or Credit card information that you provided to the pharmacy or failure of your payment authorization to them we do NOT refund the consultation 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.
Confirm selection of Brand or Generic: *
Make sure you check with your pharmacy first for price difference between the brand name and the generic Dutasteride equivalent. Brand name Avodart can be as high as $2500.  If you select brand name Avodart, there is a $25 fee to later change it to generic Dutasteride 0.5mg.
Please CONFIRM YOUR SELECTION made above: *
Regular Service is $49.95 consult fee plus $10.35 processing fee
Express 24hr Service is $49.95 consult fee plus $20 express processing fee

Click SUBMIT button (secure server) to order Avodart Initial Consultation

For any questions and fastest reply contact us by

email at wellnessmd@medicalwellnesscenter.com

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