Pain Pill Order Form

To place an order by phone or to submit Credit-Debit Card information call 1-281-726-4790.

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 and will explain why in the box below



I agree not to take medication if I am pregnant, breast-feeding, or trying to get pregnant.

I Agree   I Disagree and will explain why in the box below



Please list all current medical conditions.

None   I will specify in the box below



Is there anything in your medical history that you consider to be relevant? If yes, please specify.

None   I will specify in the box below



Please list all over-the-counter and prescription medications that you are currently taking and the length of time for each.

None   I will specify in the box below



Please list all medications that you plan to take while on this program.

None   I will specify in the box below



Please list all past or present allergies including allergies to any medications.

None   I will specify in the box below



Please list all past surgeries and provide details including the condition that was treated with each surgery.

None   I will specify in the box below



Has the prescription that you are ordering ever been prescribed to you before?

No   Yes  Date and Dr. Name provided below



Have you visited/consulted with a Physician within the last 3 months?

No   Yes  Date, Dr. Name and reason provided below



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.



Yes  No  Health Insurance

Yes  No  Ever Experienced Seizure

Yes  No  History of Liver or Kidney Disease

Yes  No  Consume Alcohol

Yes  No  Opiate Dependent

Yes  No  Taking Antidepressant or Antianxiety

Disclaimer: By checking this box I confirm that my medical history information is honest, correct and complete. I am an adult 18 years or older. I agree to pay with a Credit or Debit Card unless I have the option to use a Money Order because I am an existing patient. I am competent to use the services offered and I have reviewed the Terms of Service and agree to them fully.

I understand once I submit my order the services of the doctors, pharmacist, administration and USPS will be called upon, therefore the pharmacy will not accept any requests for cancellations or refunds. I have double checked the information and confirm that all of the information is correct.

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".

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