In order to provide your Brand Medication, we need our Doctors to review your medical history.

Identity

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

Gender

Male Yes Change

Medical History

What other medications, herbal remedies, vitamins or supplements are being taken?

Product Name

Start Date

Directions for taking

What medical condition is the medication on this order treating?

Diabetes

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.

NONE

And what other medical conditions have ever been present? If none, type none.

NONE

What surgeries has the patient had? List name and year: (If none, type none)

NONE

Please list any allergies: (if none, type none)

NONE

(Optional) Input any general notes about your health to our doctors here. This field is NOT for billing, shipping or order-related notes:

NONE

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?

Yes/No

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