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Order form

1. Your selected medication:

Acyclovir 400 mg - 90 Pills

$61.38

Coupon:

FedEx Next Day Delivery

$24.95

Total

$86.33

Shipping:

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FedEx Next Day Delivery ($24.95)

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2. Payment information:

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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.

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4. Shipping address:

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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:

Monday 10/11/2010

Your reorder price:

$61.38 *

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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: *

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Please list in detail any allergies you have to medicines, please include any previous drug reaction or interactions: *
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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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Have you ever had kidney or liver problems or bone marrow transplant?

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

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