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Order form

1. Your selected medication:

Flonase .05% - 1 x 16 gm Bottle

$150.91

Coupon:

FedEx Next Day Delivery

$24.95

Total

$175.86

Shipping:

*

FedEx Next Day Delivery ($24.95)

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Your full name:

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(no initials please)

Email:

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Please retype email:

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Save Info: Do you want us to save your personal data for future orders?

2. Payment information:

Card Type:

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Card Holder:

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Card Number:

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Expiry Date:

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CVV2 code:

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(the last 3 digits on the back of your card) help

Important: Please use your own credit card, if you are using another persons card, or if your billing address does not match the card, your order may be delayed.

3. Billing address (must match your credit card):

Address:

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City:

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Zipcode:

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Your phone:

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(use cell phone if possible)

4. Shipping address:

Use my Billing Address I will specify an Address below

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City:

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5. Auto reorder (or skip this section):

We can automatically place a new order for you when you are due to reorder (see the date below).

Auto Reorder on:

Thursday 10/7/2010

Your reorder price:

$150.91 *

Turn on Auto reorder:

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* The reorder price shown is the price of the product only, shipping is excluded.

6. Medical questionnaire:

Date of Birth:

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Your Height:

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Your Weight:

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Your Sex:

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Male Female

Is your Personal Healthcare Practitioner aware that you are requesting this medication?

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Have you been prescribed this medication before?

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Have you had a physical exam in the last 12 months?

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Please state the medical condition requiring you to use this medication IMPORTANT: your order will not be approved unless this question is answered fully: *

Do you suffer from any seasonal allergies?

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Please list in detail any allergies you have to medicines, please include any previous drug reaction or interactions: *
None

Do you permit this web site to designate the pharmacy which will fill your order?

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Are you currently under treatment for any health problems?

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Are you currently taking any prescription or non-prescription medicines: *
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Please list anything in your medical history that you think might be relevant: *
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Please list any significant family medical history: *
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Will you be taking other medications while taking this medicine?

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Please let us know whether you had any surgeries and what was the medical condition you needed surgery for: *
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Do you agree not to take any over-the-counter medicines without approval from your pharmacist?

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Do you agree not to take medication if you are pregnant, breast-feeding, or trying to get pregnant?

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I have Read and Agree with the nextdaypharmacy.org Terms & Conditions:

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I have Read and Agree with the nextdaypharmacy.org Refund Policy:

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