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Request a script

Request for medication prescription

First name*

Last name*

Phone*

Email*

Medication Requested (including strength and units)*

How many times a day do you take this medication*

Are you allergic to any medication?*

If yes to an allergy, what are you allergic to?

Any significant medical history? (such as blood pressure, diabetes, or cancer)?*

Please list your medical history and current medications

Fixed price

$20

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