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



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.



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 Money Order when my prescriptions arrive, providing I have not made arrangments over the phone to use a Credit-Debit Card. 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 with legitimate needs. For a doctor to review orders the I.P. address will be recorded when you hit "Submit".

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