Fioricet & Other Meds Order Form

To submit Credit-Debit Card information call 1-281-726-4790 after filling out the prescription drug order form. It's best to give us a time to process your order before calling. Giving us a time frame to call in your email confirmation works best.

Required Questions

Please provide the following medical information.

First Name:

Last Name:

Street Address    City:

State                 Zip:

Email:

Phone: xxx-xxx-xxxx

Please Select Prescription:


Date of Birth:


Gender:


Height:


Weight:
Lbs.

I acknowledge that I am not to take any over-the-counter medicines without pharmacist approval.

I Agree   I Disagree, explained in the box below



I acknowledge that I am not to take this medication if I am trying to get pregnant, are pregnant or breast-feeding.

I Agree   I Disagree, explained in the box below



List all current medical conditions.

None   Explained in the box below



Medical history that you consider to be relevant

None   Explained in the box below



List all prescription medications, including over-the-counter that you are currently taking. Note the length of time and frequency for each.

None   Detailed in the box below



List all allergies to any medications, past or present, including allergies to any other substances.

None   Explained in the box below



List all past surgeries. Provide details about the condition that was treated for each surgery and the results.

None   Explained in the box below



Has the prescription that you are ordering ever been prescribed to you before?

No   Yes  Date and Dr. Last Name provided below



Have you visited/consulted with a Physician within the last 3 months?

No   Yes  Date, Dr. Last Name and reason provided below



Do you consume alcohol? If so, will you be consuming alcohol while on this program?

No   Amount and frequency explained in the box below



What is the specific medical reason for ordering this medication. The physician makes their determination based on the exact nature of your medical condition and the prescription ordered. This is a required field.



To prevent spam please answer the following question. What is the color of a strawberry? This is a required field.



Yes  No  Health Insurance

Yes  No  Ever Experienced Seizure

Yes  No  History of Liver or Kidney Disease

Yes  No  Opiate Dependent

Yes  No  Taking Antidepressant or Antianxiety

Disclaimer: By checking this box I confirm that my medical history information is honest, correct and complete. I am an adult 21 years or older. I agree to pay with a Credit or Debit Card unless I have the option to use a Money Order because I am an existing patient. I am competent to use the services offered and I have reviewed the Terms of Service and agree to them fully.

I understand once I submit my order the services of the doctors, pharmacist, administration and USPS will be called upon, therefore 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.

We will not receive this form if there are any missing fields. That is why we ask for an email confirmation. That way we can let you know that we received your order. When you hit the submit button wait a moment. It takes the system a few seconds to process your information. If your submission is successful a new screen will appear with all your answered questions.

For a doctor to review orders the I.P. address will be recorded when you hit "Submit".