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Medical Questionnaire/Order Request
  The information below is needed to place your order request for medication.
We will not disclose any personal information to any outside party.
See our privacy statement for additional information.

All fields below must be filled out for order requests.
 

Then -OUR Normal IMScart ORDER/Shipping Details
 

 

Then medical form.


 


 


 

   
 
1. 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:
 
2. 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:
 
3. Please list all current medical conditions. Choose "None" if none.
None I will specify
 
4. 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
 
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.
None I will specify
 
6. Please list all medications that you plan to take while on this program. Choose "None" if none.
None I will specify
 
7. Please list all past or present allergies including allergies to any medications. Choose "None" if none.
None I will specify
 
8. 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
 
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.
 
10. I would like to be notified when my prescription should be refilled.
I Agree I DISAGREE       If you disagree, please explain why:
 


 

  Section ?: customer agreements
  To place an order, you must agree with the Customer Responsibility and Informed Consent Statements below.
Click each link to view the documents in a pop-up window.
 
I Have Read, Understand and Agree with the Customer Responsibility Statement
 
I Have Read, Understand and Agree with the Informed Consent Agreement
 

 

 
 

Click "Review/Confirm Order" to review your order request.
Credit Card will be billed by Your Company Name.

 
 

Call Our Sales Desk Now! - Toll-Free: 1-877-827-6451

Or Contact Us Now for More Details!
 

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