Pain Pill Order Form

To place an order by phone call 1-281-726-4790 between the hours of 12:pm - 6:pm Pacific / 3:pm - 9:pm EST time.

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".

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