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Before Proceeding
to the Medical Consultation Form
please read
CONTRAINDICATIONS
/PRECAUTIONS and WARNINGS
and accept the Waiver
of Liability
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| 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 contraindications, risks and side effects associated with
Aphthasol. |
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How
To Request a APHTHASOL PHYSICIAN CONSULT:
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First read
about Aphthasol and learn more about its indications and contraindications
and read and agree to the Waiver of Liability.
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Next, accurately
and truthfully complete and submit a medical consultation questionnaire
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Your medial
consultation will be reviewed by one of our Physicians and if approved
you will receive an Aphthasol prescription with 6 refills which can
be filled at any U.S. pharmacy of your choice. No medication purchase
required - you can choose any pharmacy where your medical insurance accepted.
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This physician
evaluation is RISK-FREE. If an Aphthasol prescription is not appropriate
for you there is No charge. The initial consultation fee for the
physician evaluation is only $49.95.
If you
are experiencing an acute canker sore outbreak, you can request EXPRESS
service and have your prescription called into any local pharmacy of your
choice within approximately 24 hours or less.
CONTRAINDICATIONS
Aphthasol is
the only FDA-approved TOPICAL prescription medication for the treatment
CANKER SORE mouth ulcerations in healthy immunocompetent individuals.
Aphthasol use is CONTRAINDICATED and must NOT be used in anyone with the
following conditions:
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Do NOT use
Aphthasol if you are pregnant, attempting to become pregnant, or at a high
risk of becoming pregnant. Aphthasol ( amlexanox oral paste 5%) is
a Pregnancy Category B which means that animal studies did not indicate
any significant fetal malformations, but there are NO adequate studies
of topically applied ciclopirox in pregnant women and therefore may pose
potential risk to the fetus
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Do NOT use
Aphthasol if you are breast feeding.
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Do NOT use
Aphthasol if you are allergic or sensitive to any of the ingredients:
amlexanox in a solution base containing benzyl alcohol, gelatin, glyceryl
monostearate, mineral oil, pectin, petrolatum, and sodium carboxymethylcellulose.
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Aphthasol is
contraindicated if you have a history of immunosuppression or immune system
disease, if you are HIV-positive, if you are on cancer chemotherapy treatment.
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Aphthasol is
NOT approved for pediatric use, and we do NOT prescribe Aphthasol to anyone
under the age of 18
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Aphthasol is
ONLY approved for use on canker sore lesions inside the mouth area
IMPORTANT
PRECAUTIONS and WARNINGS
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Aphthasol oral
paste is for TOPICAL USE ONLY on canker sores inside the mouth area.
Avoid getting Aphthasol in your eyes, nose or mouth. Flush with water
and seek immediate medical attention!
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If significant
healing or pain relief has not occurred in 10 days, seek immediate
medical attention from your regular physician.
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Aphthasol is
only indicated for people with normal immune systems.
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Keep away from
children
ADVERSE
REACTIONS - SIDE EFFECTS:
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The majority
of patients using Aphthasol experience no side effects. The
adverse reactions reported by 1 - 2% of patients using Aphthasol
are transient pain, stinging and/or burning at the site of application.
In less than 1% contact mucositis, nausea and diarrhea were reported.
If you experience increasing redness, progressive ulceration and increasing
pain after 10 days of using Aphthasol, contact your doctor immediately!
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If you get
the medication in your eyes, rinse immediately with water and contact your
regular physician!
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There are NO
systemic effects when used appropriately
IMPORTANT
PATIENT INSTRUCTIONS
HOW TO USE APHTHASOL
- Easy to Use:
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Aphthasol paste
should be applied as soon as possible after noticing the symptoms of a
canker sore.
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Aphthasol
should be applied four times daily, preferably following oral hygiene after
breakfast, lunch, dinner and at bedtime.
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Before applying
wash your hands.
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Dry the ulcer
or ulcers by gently patting it with a soft, clean cloth.
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Moisten the
tip of your index finger.
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Squeeze a dab
of paste approximately 1/4 inch (0.5 cm) onto your finger tip.
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Gently dap
the Aphthasol onto each ulcer in the mouth.
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Wash your hands
when you are done applying Aphthasol.
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Do not eat
or drink for 30 minutes after apply Aphthasol as the medication would be
washed away.
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Use this medication
4 times/ day until the ulcer heals.
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If significant
healing or pain reduction has not occurred in 10 days, consult your regular
physician.
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I DO NOT HAVE ANY OF THE
ABOVE CONTRAINDICATIONS:
By accepting "I Agree" means that
you have read the above contraindication, precautions and warnings and
honestly acknowledge that you do not have any of the above contraindications
to APHTHASOL therapy. Also, that I am aware of the side effects !
I fully understand that Aphthasol is indicated only canker sores in the
mouth in immunocompetent individuals. Aphthasol is contraindicated
in anyone with a compromised immune system , as it has not been tested,
such as but not limited to HIV-positive on cancer chemotherapy etc.
I understand that it is solely my responsibility to seek diagnostic and
medical treatment for any underlying medical conditions from my own regular
primary care physician. |
 
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