Request for Astelin nasal spray 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:

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Notice:  We do NOT ship prescription medicines to residents of Missouri

Note to international clients:  Country selection is located on the payment & shipping page.

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Current Medications: 

Medication Allergies:

Medical Conditions or Chronic Diseases:

Chief Current Complaint (e.g. allergies):

Please describe your symptoms: 

How often do symptoms occur? 

How long ago did you first experience these symptoms? 


Do you suffer from bronchial asthma, or other lower respiratory conditions, glaucoma, any

cardiovascular disorders, hypertension, prostate conditions, or urinary retention?

Yes  No

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Patients are hereby advised that Astelin should not be used by patients with bronchial asthma or other lower respiratory symptoms, glaucoma, cardiovascular disorders, hypertension, prostate conditions or urinary retention, or children under 12 years old.  By clicking the continue button below I state that I have answered all questions truthfully to the best of my knowledge and ability.

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