Choose Your Order Here ---------------------------------------------------- Generic Fioricet 40mg - 90 Tabs - $179 Generic Fioricet 40mg - 120 Tabs - $209 Generic Fioricet 40mg - 180 Tabs - $259 ---------------------------------------------------- Cyclobenzaprine 10mg - 90 Tabs - $129 Cyclobenzaprine 10mg - 120 Tabs - $149 Cyclobenzaprine 10mg - 180 Tabs - $169 ---------------------------------------------------- Gabapentin 300mg - 90 Tabs - $139 Gabapentin 300mg - 120 Tabs - $149 Gabapentin 300mg - 180 Tabs - $169 ---------------------------------------------------- Gabapentin 400mg - 30 Tabs - $119 Gabapentin 400mg - 90 Tabs - $149 Gabapentin 400mg - 120 Tabs - $169 Gabapentin 400mg - 180 Tabs - $189 ---------------------------------------------------- Gabapentin 600mg - 30 Tabs - $129 Gabapentin 600mg - 90 Tabs - $179 Gabapentin 600mg - 120 Tabs - $209 Gabapentin 600mg - 180 Tabs - $249 ---------------------------------------------------- Gabapentin 800mg - 30 Tabs - $129 Gabapentin 800mg - 90 Tabs - $189 Gabapentin 800mg - 120 Tabs - $219 Gabapentin 800mg - 180 Tabs - $269
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1. I agree not to take any over-the-counter medicines without approval from my pharmacist.
I Agree I Disagree
2. I agree not to take this medication if I am pregnant, breast feeding, or trying to get pregnant.
3. Please list all current medical conditions including high blood pressure. Choose "None" if none.
None I will specify
4. Is there anything in your medical history that you consider to be relevant? If yes, please specify. Choose "None" if none.
5. Please list all over-the-counter and prescription medications that you are currently taking and the frequency for each. Choose "None" if none.
6. Please list all past or present allergies including allergies to any medications. Choose "None" if none.
7. Please list all past surgeries and provide details including the condition that was treated with each surgery. Choose "None" if never.
8. Have you been treated with opiates, nitrates or narcotics or are you considered an opiate dependent patient? If yes, please specify. Choose "None" if no.
9. Have you been treated for any kind of mental health, substance abuse or emotional problem? Choose "None" if never.
10. Have you ever experienced or been treated for a seizure? Choose "None" if never.
11. Do you have a history of liver or kidney disease? Choose "None" if no.
12. Do you drink alcohol? If yes, please specify. Choose "None" if no.
13. Have you taken this medication before? Please specify date and from where. Choose "None" if never.
14. 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.
Disclaimer: By submitting this order I am confirming that the medical questionnaire contains my full and honest medical history, which I have answered truthfully and that I am an adult (at least 18 years of age). I am competent to use the services offered and I have reviewed the Terms of Service and agree to them fully.
I understand that once my order is submitted requests for cancellations or refunds are not allowed. I have double checked the information and confirm that all of the information is correct, and I will pay with a money order upon delivery (no cash is accepted).
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