newcustomers

This form is for new customers only. Refill customers please use returned customers only websites (check the email we sent you for these URLs).

Order processing from this form is slower because we have to verify the new customer information.

Please chose Your Order

Please confirm your order

1. I want to pay you by:

Which COD pharma do you want to place your order ?

Personal Details

Your First Name :

Your Last Name :

Your Email :

Your Phone:

Your Zip Code:

Billing and Shipping Address

Street Address:

City:

State:

Country:

Health Questionnaires

Date of Birth: mm/dd/year

Your Height: ft-in

Your Weight: Lbs

Gender:

1. I agree not to take any over-the-counter medicines without approval from my pharmacist.

If you disagree, please explain why:

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

If you disagree, please explain why:

3. Please list all current medical conditions including high blood pressure. Choose "None" if none.

Specify all current medical conditions:

4. Is there anything in your medical history that you consider to be relevant? If yes, please specify. Choose "None" if none.



5. 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.



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



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



8. Please list all past surgeries and provide details including the condition that was treated with each surgery. Choose "None" if none.



9. 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.

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 will never overdose the medicine. I also know the order cannot be cancelled when I click "place order now" link