ALL-RX

Choose Your Product

* Choose Your Product

* Shipping Option USPS Priority Mail Free USPS Express Mail $ 15.00

Acyclovir 400mg 30 Tablets - $109.00 $109

Customer Information

Shipping Address

First Name

Last Name

Street

City

State

Zip/Postal Code

Cell Phone Number

Email Address

check,if billing address is same as shipping address.

Billing Address

First Name

Last Name

Street

City

State

Zip/Postal Code

Payment Details

We accept Visa, MasterCard and Amex

Enter a name for this Card

Credit Card Number*

Expiration Date*

Exp Date*

CVV Code*

What is CVV

Health Questionnaire

Date of Birth

Gender

Height ft-in

Weight lbs

1. I agree not to take any over-the-counter medicines without approval from my pharmacist.

Please describe:

2. I agree not to take this medication if I am pregnant, breast feeding, or trying to get pregnant.

Please describe:

3. Please list any and all medical conditions such as chest pain, heart disease, high blood pressure, seizure disorder, stroke, etc. Choose "None" if none.

Please describe:

4. Is there anything in your medical history that you consider to be relevant? If yes, please specify. Choose "None" if none.

Please describe:

5. Please list all over-the-counter and prescription medications that you are currently taking and the frequency for each. Choose "None" if none.

Please describe:

6. Please list all past or present allergies including allergies to any medications. Choose "None" if none.

Please describe:

7. Are you currently taking any controlled substances (for example certain anti-anxiety medications, sleep medications, or pain medications)? Please list all medications you are currently taking. Choose "None" if none. Note: The pharmacy and provider may verify prescription history.

Please describe:

8. Are you currently taking or have you recently taken any of the following medications? Opioids, narcotic pain medications, nitrates or nitroglycerin medications? Suboxone or other medications used to treat opioid dependence. If yes, please specify. Choose "None" if none.

Please describe:

9. Have you been treated for any kind of mental health, substance abuse or emotional problem? Choose "None" if never.

Please describe:

10. Have you ever experienced or been treated for a seizure? Choose "None" if never.

Please describe:

11. Do you have a history of liver or kidney disease? Choose "None" if no.

Please describe:

12. Do you currently have a primary care physician or healthcare provider who manages your general medical care?
Yes No 13. Do you drink alcohol? If yes, please specify. Choose "None" if no.

If you disagree please explain why:

14. Have you taken the medication you are requesting before? Please specify approximate date and from where (for example: primary care doctor, telehealth service, or pharmacy).

15. 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.

Disclaimer: By submitting this order, I confirm that the medical questionnaire I have completed contains my full and accurate medical history and that all information provided is true and correct to the best of my knowledge. I confirm that I am an adult (at least 21 years of age) and that I am competent to use the services offered.

I acknowledge that I have reviewed and agree to the Terms of Service and Privacy Policy. I understand and agree that the pharmacy and/or medical provider may review my prescription history, for the purpose of evaluating my eligibility for treatment and fulfilling my order. I understand that providing false, misleading, or incomplete medical information may result in denial of service or cancellation of my order. I understand that once my order has been processed and shipped by the pharmacy, cancellations or refunds will not be accepted.

By submitting this order, I confirm that I have reviewed all information provided and verify that it is accurate and complete to the best of my knowledge. I understand that telehealth services are not intended to replace ongoing care from a primary healthcare provider, and I am responsible for seeking in-person medical care when appropriate.

I confirm that I have read and agree to the Telehealth Consent & Order Authorization above.

Verify code:

About us

Choose Your Product

Customer Information

Shipping Address

Billing Address

Payment Details

Health Questionnaire