Step Request for Carbinoxamine 4mg Tablets 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.



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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.

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Please describe your symptoms: 

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Do you suffer from bronchial asthma, or other lower respiratory conditions, glaucoma, prostate conditions, or urinary retention?

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Patients are hereby advised that this product should not be used by patients with bronchial asthma or other lower respiratory symptoms, glaucoma, prostate conditions or urinary retention.  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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If you would prefer to pay by check please follow the directions below:

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 application should not be approved. Mail this page with your payment ($47.99 Rx + $5 professional fee + SHIPPING & HANDLING choice) check or money order payable to WebRx Pharmacy Palace to:

6583 Gateway Ave

Sarasota, FL 34231

 See shipping details.

If you would prefer to fax the information please print, click reset, and fax it to (941)296-7447 then click here to make payment.

Privacy Statement:  No information is collected until the button above 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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