Request for Erythromycin Topical Solution Prescription:

Last Name:   First:

Middle:

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

State:  

Zip:
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. acne):
Where are blemishes located? (e.g. face)
Where will you be using the erythromycin? (e.g. face)
How long have you had this condition?
What else are you using to treat acne?

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.

Patients approved for a prescription for erythromycin topical solution are hereby advised that this product should not be used near deep or puncture wounds.

 

By signing below I attest that I have read the above statements and have truthfully answered all questions to the best of my knowledge and understanding:

 

signature / date

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 ($17.99 Rx + $5 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 Priority Mail, $18 2nd Day, $26 Next Business day.  See details.