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: FL Zip:

Notice:  Within the USA, this product can only be shipped to Florida residents.

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):

Note: We will only approve this medication for treatment of oral herpes (cold sores) on the lips.

Location of use:

If for a recurring condition, how long have you had this condition?

How often do symptoms occur?

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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:

RxPalace 6583 Gateway Ave Sarasota, FL 34231

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.

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