COD ORDER FORM

All information that will be specified by you in the form below will be uploaded to US licensed pharmacy and reviewed by US licensed pharmacist. We do not store customer information online.

Money Order is only accepted.
All support is provided only by email.
Free USPS Priority Mail shipping.

Select Your Order

Medicine *

Health Questionnaires

Please explain the chief complaint that prompted you to request this Medication. We must know the exact nature of your medical problem in order to prescribe any medication(s) This must be answered as thoroughly as possible. This cannot be left blank. *

Any radiation of pain anywhere? Type "nothing" below If nothing. *

Please list all current medical conditions. Type "nothing" below If nothing. *

Please list all over the counter and prescription medications that you are taking and the length of time you have been taking them. Type "nothing" below If nothing. *

Please list any allergies to any medications. Type "nothing" below If nothing. *

List all the Surgeries in the past. Type "nothing" below If nothing. *

Do you smoke or use any tobacco products? If Yes, please list the number of packs per day and since when? Type "nothing" below If nothing. *

Do you consume alcohol? If Yes, please explain what you drink and how much and how often? Type "nothing" below If nothing. *

Have you seen a doctor for your complaints? Type "nothing" below If nothing. *

Name of your Primary Physician?

Does your Primary Physician knows about this condition?

Yes

No