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* Shipping Option USPS Priority Mail Free USPS Express Mail $ 15.00

Acyclovir 200mg 90 Tablets - $119.00 $119

Customer Information

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First Name

Last Name

Street

City

State

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COD Credit Card

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Health Questionnaire

Date of Birth

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Weight lbs

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

Please describe:

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

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

Please describe:

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

Please describe:

5. Please list all over-the-counter and prescription medications that you are currently taking and the frequency for each. Choose "None" if none.

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

Please describe:

7. Please list all past surgeries and provide details including the condition that was treated with each surgery. Choose "None" if never.

Please describe:

8. Have you been treated with opiates, nitrates or narcotics or are you considered an opiate dependent patient? If yes, please specify. Choose "None" if no.

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9. Have you been treated for any kind of mental health, substance abuse or emotional problem? Choose "None" if never.

Please describe:

10. Have you ever experienced or been treated for a seizure? Choose "None" if never.

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11. Do you have a history of liver or kidney disease? Choose "None" if no.

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12. Do you drink alcohol? If yes, please specify. Choose "None" if no.

If you disagree please explain why:

13. Have you taken this medication before? Please specify date and from where. Choose "None" if never.

Add date of last visit:

14. 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 submitting this order I am confirming that the medical questionnaire contains my full and honest medical history, which I have answered truthfully and that I am an adult (at least 21 years of age). I am competent to use the services offered and I have reviewed the Terms of Service and agree to them fully.
I understand that once my order has been shipped 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. If paying with a money order upon delivery (no personal checks are accepted). All orders are shipped via USPS.

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Customer Information

Health Questionnaire