Step Request for Analpram HC 2.5% Cream or generic equivalent:

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: Cell Phone: Enter 0 if no cell phone

Email Address: (i.e. bob@aol.com) Landline Phone: Enter 0 if no landline

Address: City: State: 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. hemorrhoids):
Location of use (e.g. rectally):
If for a recurring condition, how long have you had this condition?
How often do symptoms occur?

Selection of Ointment or Cream, quantity desired, and shipping options are located on the next 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:

RxPalace.com

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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