Request for Denavir Prescription:

Last Name:   First:

Middle:

Daytime Phone:
Email: (i.e. bob@aol.com) Evening Phone:
Address: City:

State:  

Zip:

Notice:  We do NOT ship prescription medicines to residents of Missouri
Male Female 

Date of Birth:

Are you pregnant or nursing a baby?
Current Medications:
Medication Allergies:
Medical Conditions or Chronic Diseases:
Chief Current Complaint (e.g. Cold Sores):
Are sores located? (e.g. on lips, inside mouth, face)
How long have you had this condition?
How often do symptoms occur?

If you have a discount or rebate code please enter it here: OPTIONAL

Enter the name of the referrer here: OPTIONAL

After you have completed all fields above, please print out this page. Thank you. Please send any additional information to us that would help by email or write it down on the reverse side of the application form. Click here to return to WebRx Pharmacy Palace or click here to return to the previous page.

Your prescription, if approved, will be filled by our pharmacist. You will not be charged and your check or money order will be returned if it is determined by the pharmacist that your application should not be approved. Mail this page with your payment ($49.99 Rx + $30 professional fee + SHIPPING & HANDLING choice) check or money order payable to WebRx Pharmacy Palace to:

WebRx Pharmacy Palace

501 N. Beneva Rd, Suite 550

Sarasota, FL 34232

 Shipping & Handling Options: $9 Standard, $18 2nd Day, $26 Next Business day.  See details.