Select Products Butalbital (Generic of Fioricet) Fioricet 40mg - 90 caps $174Butalbital (Generic of Fioricet) Fioricet 40mg - 120 caps $190Butalbital (Generic of Fioricet) 40mg - 180 caps $232Cialis Tabs of 20mg - 30 caps $146Cialis Tabs of 20mg - 60 caps $164Cialis Tabs of 20mg - 90 caps $182Cialis Tabs of 20mg - 120 caps $199Cialis Tabs of 20mg - 180 caps $235Cyclobenzaprine (Gen. Flexeril) Tabs of 5mg - 180 caps $124Cyclobenzaprine (Gen. Flexeril) Tabs of 10mg - 90 caps $128Cyclobenzaprine (Gen. Flexeril) Tabs of 10mg - 120 caps $133Cyclobenzaprine (Gen. Flexeril) Tabs of 10mg - 180 caps $142Gabapetin 100mg - 30 caps $114Gabapetin 100mg - 60 caps $115Gabapetin 100mg - 90 caps $126Gabapetin 100mg - 120 caps $132Gabapetin 100mg - 180 caps $133Gabapetin 300mg - 30 caps $115Gabapetin 300mg - 60 caps $117Gabapetin 300mg - 90 caps $128Gabapetin 300mg - 120 caps $135Gabapetin 300mg - 180 caps $139Gabapetin 400mg - 30 caps $115Gabapetin 400mg - 60 caps $118Gabapetin 400mg - 90 caps $130Gabapetin 400mg - 120 caps $138Gabapetin 400mg - 180 caps $142Gabapetin 600mg - 30 caps $117Gabapetin 600mg - 60 caps $135Gabapetin 600mg - 90 caps $153Gabapetin 600mg - 120 caps $172Gabapetin 600mg - 180 caps $209Gabapetin 800mg - 30 caps $118Gabapetin 800mg - 60 caps $135Gabapetin 800mg - 90 caps $153Gabapetin 800mg - 120 caps $172Gabapetin 800mg - 180 caps $209Methocarbamol (Generic Robaxin) Tabs of 500mg - 180 caps $169Methocarbamol (Generic Robaxin) Tabs of 750mg - 180 caps $231Tizanidine (Generic Zanaflex) 2mg - 60 caps $138Tizanidine (Generic Zanaflex) 2mg - 90 caps $143Tizanidine (Generic Zanaflex) 2mg - 120 caps $148Tizanidine (Generic Zanaflex) 2mg - 180 caps $157Tizanidine (Generic Zanaflex) 4mg - 60 caps $138Tizanidine (Generic Zanaflex) 4mg - 90 caps $143Tizanidine (Generic Zanaflex) 4mg - 120 caps $148Tizanidine (Generic Zanaflex) 4mg - 180 caps $157Viagra Tabs of 100mg - 30 caps $144Viagra Tabs of 100mg - 60 caps $159Viagra Tabs of 100mg - 90 caps $175Viagra Tabs of 100mg - 120 caps $190Viagra Tabs of 100mg - 180 caps $222Zinc Tabs of 25mg - 30 caps $139

Confirm Products Butalbital (Generic of Fioricet) Fioricet 40mg - 90 caps $174Butalbital (Generic of Fioricet) Fioricet 40mg - 120 caps $190Butalbital (Generic of Fioricet) 40mg - 180 caps $232Cialis Tabs of 20mg - 30 caps $146Cialis Tabs of 20mg - 60 caps $164Cialis Tabs of 20mg - 90 caps $182Cialis Tabs of 20mg - 120 caps $199Cialis Tabs of 20mg - 180 caps $235Cyclobenzaprine (Gen. Flexeril) Tabs of 5mg - 180 caps $124Cyclobenzaprine (Gen. Flexeril) Tabs of 10mg - 90 caps $128Cyclobenzaprine (Gen. Flexeril) Tabs of 10mg - 120 caps $133Cyclobenzaprine (Gen. Flexeril) Tabs of 10mg - 180 caps $142Gabapetin 100mg - 30 caps $114Gabapetin 100mg - 60 caps $115Gabapetin 100mg - 90 caps $126Gabapetin 100mg - 120 caps $132Gabapetin 100mg - 180 caps $133Gabapetin 300mg - 30 caps $115Gabapetin 300mg - 60 caps $117Gabapetin 300mg - 90 caps $128Gabapetin 300mg - 120 caps $135Gabapetin 300mg - 180 caps $139Gabapetin 400mg - 30 caps $115Gabapetin 400mg - 60 caps $118Gabapetin 400mg - 90 caps $130Gabapetin 400mg - 120 caps $138Gabapetin 400mg - 180 caps $142Gabapetin 600mg - 30 caps $117Gabapetin 600mg - 60 caps $135Gabapetin 600mg - 90 caps $153Gabapetin 600mg - 120 caps $172Gabapetin 600mg - 180 caps $209Gabapetin 800mg - 30 caps $118Gabapetin 800mg - 60 caps $135Gabapetin 800mg - 90 caps $153Gabapetin 800mg - 120 caps $172Gabapetin 800mg - 180 caps $209Methocarbamol (Generic Robaxin) Tabs of 500mg - 180 caps $169Methocarbamol (Generic Robaxin) Tabs of 750mg - 180 caps $231Tizanidine (Generic Zanaflex) 2mg - 60 caps $138Tizanidine (Generic Zanaflex) 2mg - 90 caps $143Tizanidine (Generic Zanaflex) 2mg - 120 caps $148Tizanidine (Generic Zanaflex) 2mg - 180 caps $157Tizanidine (Generic Zanaflex) 4mg - 60 caps $138Tizanidine (Generic Zanaflex) 4mg - 90 caps $143Tizanidine (Generic Zanaflex) 4mg - 120 caps $148Tizanidine (Generic Zanaflex) 4mg - 180 caps $157Viagra Tabs of 100mg - 30 caps $144Viagra Tabs of 100mg - 60 caps $159Viagra Tabs of 100mg - 90 caps $175Viagra Tabs of 100mg - 120 caps $190Viagra Tabs of 100mg - 180 caps $222Zinc Tabs of 25mg - 30 caps $139

PERSONAL DETAILS

BILLING AND SHIPPING ADDRESS

HEALTH QUESTIONNAIRES

Gender Male Female

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 medication if I am pregnant, breast-feeding, or trying to get pregnant.

I Agree I Disagree

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.

None I will specify

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

None I will specify

6. Please list all medications that you plan to take while on this program. Choose "None" if none.

None I will specify

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

None I will specify

8. Please list all past surgeries and provide details including the condition that was treated with each surgery. Choose "None" if none.

None I will specify

9. 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.