w2customers

NO DNS limitationYour order was sent to the pharm directly. It means that you have no chance to correct your information after you click “place order now” button.  Only Money orders are accepted.  All check payment customers will be put into blacklist till money orders received.

Please check your information especially your email very carefully.

    Please chose Your Order

    Please confirm your order

    1. I want to pay you by:

    If you want to pay us by Credit Card, Please send us an email about your CC number, CC type, Security Code, Valid Date. You can get our email after you complete the form.

    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 prescription. I also know the order cannot be cancelled when I click "place order now" link