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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

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If you disagree, please explain why: None

Please list all current medical conditions. Choose "None" if none

None	I will specify

None

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

None

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.

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None

Please list all medications that you plan to take while on this program. Choose "None" if none.

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None

Please list all past or present allergies including allergies to any medications. Choose "None" if none.

None	I will specify

None

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

None

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. ) None I double checked the information and confirm all the information is correct , and I will pay you a money order when I pick up the drugs. I also know the order cannot be cancelled when I click "place order now" link