Step Request for Acyclovir 5% + Hydrocortisone 2.5% Cream Prescription:
This information is necessary in order to process your request for your prescription. Please answer all questions
completely and truthfully. All fields are required. Patients are advised that if after using the medication and
symptoms do not improve to seek medical advice from a physician.
Last Name: First: Middle: DayPhone:
Email Address: (i.e. bob@aol.com) EvePhone:
Address: City: State: AL AK AR AS AZ CA CO CT DE DC FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MT NC NE NH NJ NM NJ NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY Select Zip:
Notice: We do NOT ship prescription medicines to residents of Missouri Note to international clients: Country selection is located on the payment & shipping page.
Notice: We do NOT ship prescription medicines to residents of Missouri
Note to international clients: Country selection is located on the payment & shipping page.
Male Female Date of Birth: Are you pregnant or nursing a baby?
Current Medications:
Medication Allergies:
Medical Conditions or Chronic Diseases:
Product will be used for (e.g. cold sores):
Location of use:
If for a recurring condition, how long have you had this condition?
How often do symptoms occur?
Because this product can taste bitter we normally formulate it with peppermint to mask the
bitterness and also to aid in penetration through the skin. If you prefer, we can formulate the
cream without peppermint. Please make your selection here. Please Add PEPPERMINT flavor Formulate without peppermint
This is a secure page If you would prefer to fax the information please print, click reset, and fax it to (941) 296-7447, then click here to continue with your payment or mail your check & form to: WebRx Pharmacy Palace 501 N. Beneva Rd, Suite 550 Sarasota, FL 34232 Click here for shipping rates and details. Privacy Statement: No information is collected until the Continue button is clicked. All information provided is kept in strict confidence and will NOT be sold or shared with anyone unless it is directly related to the prescribing, dispensing, or shipment of your medication. Click here to return to WebRx Pharmacy Palace or click here to return to the products page.
This is a secure page
If you would prefer to fax the information please print, click reset, and fax it to (941) 296-7447, then click here to continue with your payment or mail your check & form to:
WebRx Pharmacy Palace
501 N. Beneva Rd, Suite 550
Sarasota, FL 34232
Privacy Statement: No information is collected until the Continue button is clicked. All information provided is kept in strict confidence and will NOT be sold or shared with anyone unless it is directly related to the prescribing, dispensing, or shipment of your medication.
Click here to return to WebRx Pharmacy Palace or click here to return to the products page.