In order to provide your Brand Medication, we need our Doctors to review your medical history.
What is the full legal name of who the medications are for? We have taken this from your account information and just need to confirm it.
Bruce Eric Brown Yes Change
Date of Birth
1 February 1952 Yes Change
Male Yes Change
What other medications, herbal remedies, vitamins or supplements are being taken?
Directions for taking
What medical condition is the medication on this order treating?
Are there any other medical conditions now, or in the past, that could affect taking any items you’ve ordered? If yes, please list. If none, type none.
And what other medical conditions have ever been present? If none, type none.
What surgeries has the patient had? List name and year: (If none, type none)
Please list any allergies: (if none, type none)
(Optional) Input any general notes about your health to our doctors here. This field is NOT for billing, shipping or order-related notes:
Have you read the information page on the medicine(s) you’re ordering, and confirm that you are using them according to the product instructions?
Doctor / Physician Information
This information is required for our records, do NOT enter your own information below. If you don’t have a doctor you’ve seen recently, enter the information of the last doctor you’ve seen.
First Name Last Name
Email Address: email
Phone Number: Number
Fax Number: Number