Pain Pill Order Form

Visa/AMEX Order Recommended Site for Credit Card Orders

PainPillPharmacy.com Amex, Visa, Master Card Prescription Drug Recommended Website

Required Questions

Please provide the following medical information.

First Name:

Last Name:

Street Address          City                 State  Zip:
(No PO Box)
Email:

Phone: xxx-xxx-xxxx

Please Select Prescription:


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 with a money order when my prescriptions arrive.


This order form is for legitimate people that are submitting their information to our doctors. For this reason the I.P. address will be recorded when you hit "Submit".