Request for TransDerm-Scop Prescription:

Last Name:First: Middle: DayPhone:

Email Address:  EvePhone:

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:

Do you have any diseases of the eye(s) such as glaucoma or eye pain? Yes   No

Do you have any diseases of the prostate or difficulty urinating?  Yes  No

Do you have an allergy to scopolamine or belladonna alkaloids?  Yes  No

Chief Current Complaint (e.g. travel sickness):

Please describe your symptoms & when they occur: 

Will you be using any other medication or devices to treat motion sickness?  If yes, please

list what you will use.  If no, please write "none".

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 products page.

Patients approved for a prescription for Transderm-Scop patches are hereby advised that if eye pain develops while using this medication that it may

be a sign of a serious condition and should seek appropriate medical attention.

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 request should not be approved. Mail this page with your check or money order ($89.99 Rx + $5 professional fee + s/h) payable to WebRx Pharmacy Palace to: