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Please provide the following medical information.

All fields are required.

First Name *:

Last Name *:

Street Address:            

City:                                          State:                 Zip:  
    

Email *:

Phone: xxx-xxx-xxxx

Please select your prescription: (required)

Date of Birth:

Gender:

Height:

Weight: (lbs)

I agree not to take any over-the-counter medicines without approval from my pharmacist
 I Agree I Disagree
If you disagree, please explain why:

I agree not to take medication if I am pregnant, breast-feeding, or trying to get pregnant.
 I Agree I Disagree
If you disagree, please explain why:

Please list all current medical conditions. Choose "None" if none.
 None I will specify

Is there anything in your medical history that you consider to be relevant? If yes, please specify. Choose "None" if none.
 None I will specify

Please list all over-the-counter and prescription medications that you are currently taking and the length of time for each. Choose "None" if none.
 None I will specify

Please list all medications that you plan to take while on this program. Choose "None" if none.
 None I will specify

Please list all past or present allergies including allergies to any medications. Choose "None" if none.
 None I will specify

Please list all past surgeries and provide details including the condition that was treated with each surgery. Choose "None" if none.
 None I will specify

Please explain the specific medical reason for ordering this medication. The physician must know the exact nature of your medical problem in order to prescribe this medication.(This cannot be left blank.)

All the information is correct and I agree to pay using my credit card.

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